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Promoting evidence-based health care in Africa Countries with major public health challenges do not always base their health-care decisions on the best available scientific evidence. Charles Shey Wiysonge tells Fiona Fleck how he and his colleagues are trying to change that.
Q: How did you become interested in medicine and public health? Charles Shey Wiysonge is devoted to encouraging A: Growing up in Cameroon I better use of scientific evidence for health policies and wanted to study mathematics and programmes in African countries. He is the director of was drawn to complex equations and the South African Cochrane Centre, a unit of the South aeronautics, but people said I should African Medical Research Council, and a professor of study medicine, so I did. At medical epidemiology and biostatistics at the department of school most students wanted to become Global Health in the Faculty of Medicine and Health clinical specialists, public health was Sciences at Stellenbosch University in South Africa. He not popular at all. After graduating, Wiysonge Courtesy of Charles Shey several things drew me to public health. Charles Shey Wiysonge was Chief Research Officer at the Joint United Nations I worked as a hospital physician and saw Programme on HIV/AIDS 2006–2007 and a Medical several outbreaks of measles. People Research Council Africa Fellow at the University of Cape Town (UCT) 2004–2006. used to say “don’t count your children In Cameroon, he worked for the National Ministry of Public Health 1998–2004. until measles have come and gone.” From 1995 to 1998, he was a physician at the University Teaching Hospital in Children were dying of measles every Yaoundé, Cameroon. He is a member of several editorial boards and joined day. This experience eventually led me the World Health Organization’s (WHO) Strategic Advisory Group of Experts to work on immunization. Also, while on immunization in 2016. He graduated in medicine from the University of working in internal medicine, there were Yaoundé I in 1995, earned his Master’s degree in epidemiology from Cambridge several treatment options for hyperten- University in the United Kingdom of Great Britain and Northern Ireland and a sion and heart disease. I was not always Doctor of Philosophy in vaccinology from UCT. sure which was the best. That’s when I discovered evidence-based medicine. At that time – around the year 2000 – the Cochrane Collaboration started a new the term “evidence-based health care” countries, but more needs to be done at fellowship to train leaders in evidence- for a more holistic approach. the undergraduate and the postgraduate based medicine from low- and middle- levels across the continent. income countries. I applied, became the first holder of the award and trained at There are Q: The Cochrane Collaboration prepares the Cochrane Centre in Oxford. and disseminates information on what many examples of “ works and what doesn’t in health care Q: What is evidence-based medicine? unspeakable and globally. How is the South African Co- A: Research and other evidence are unnecessary suffering chrane Centre doing this in Africa? constantly changing and health-care resulting from the A: Our centre was set up in 1997 professionals need to keep up with the failure to take an as a unit of the South African Medical latest developments so they can offer evidence-based Research Council. It is the only Cochrane the interventions that are known to approach. centre in Africa and has a branch in work and not those that are harmful or Nigeria. There is increasing recognition ineffective. There are many examples of ” in sub-Saharan African countries, that unspeakable and unnecessary suffer- policy-making should be based on the ing resulting from the failure to take best available scientific evidence. To this an evidence-based approach to clinical Q: You did not learn about evidence- end, we have been training researchers in care. For example, in 1999 Cochrane re- based health care at medical school, is these countries to do systematic reviews searchers did a systematic review to find it included in medical curricula today? and recently expanded these activities out whether drugs that inhibited mas- A: Some medical and dental schools via the recently established Cochrane sive calcium influx into cells reduce the in South Africa offer separate courses African Network. The Cochrane Collabo- risk of death or dependency after stroke. on evidence-based health care, others ration charges a fee to access its global At the time, stroke patients were widely have embedded the approach in all library of systematic reviews and other treated with calcium channel blockers. courses, and some do both. Our Co- evidence. Low-income countries can They found no evidence of a beneficial chrane collaborators at the universities access this evidence via a special online effect. Evidence-based medicine has of Calabar in Nigeria and Yaoundé I in platform, thanks to the Evidence Aid ini- been defined as the “conscientious, ex- Cameroon also offer programmes in the tiative. In South Africa, free access to the plicit and judicious use of current best evidence-based approach for physicians. Cochrane Library is now provided by the evidence in making decisions about the Evidence-based health care is included South African Medical Research Coun- care of individual patients”, although in the curricula for health-care profes- cil and we hope other middle-income today, health-care professionals prefer sionals in these and some other African countries in Africa will follow this model.
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Q: Are the Cochrane reviews useful in cate for the dissemination and use of the evidence because it’s not what they Africa too, or do countries in Africa need evidence, and building partnerships to want to hear. For example, the South evidence that is tailored to their specific promote evidence-informed health care African Department of Health once situation? in collaboration with decision makers. asked the South African Cochrane Cen- A: Not all Cochrane reviews are ap- African countries sometimes develop tre to prepare a review of the evidence plicable to Africa. Since 2007, the South new guidelines, but often adopt or on how best to prevent mother-to-child African Cochrane Centre has collaborated adapt existing WHO guidelines to suit transmission of HIV infection. But when with the Centre for Informed Health national contexts. Our analyses of the we gave them the review, they ignored it. Choices in Norway and others to improve development or contextualization of the use of reliable research evidence guidelines used in African countries Q: Have you noticed any improvement in policy and management decisions reveals deficiencies in the rigour of in the uptake of evidence in health in Africa. We found, overall, that most development and adherence to inter- policy-making? primary studies on health system issues national reporting standards. We advise A: We have seen a positive change are from high-income countries and that countries on how to develop guidelines in attitudes towards the use of evidence only some of these reviews are applicable for their specific national contexts. We in health-care planning. For example, in low-income settings, including parts try to work with the health ministries the Paediatric Association of Kenya of sub-Saharan Africa. For this reason, through expert groups to encourage has been using explicit, transparent reviews that synthesize such studies have governments to base their policies on guideline development procedures when limited relevance to Africa, especially the best available evidence and we are developing recommendations for the those written by researchers with no ex- involved in initiatives, such as the Effec- prevention and treatment of childhood perience in Africa. tive Health Care Research Consortium, conditions for the last decade. Another an international group with partners in example is the increasing number of Q: So more research is needed that is Cameroon, Kenya, Nigeria and South African countries with functioning na- specific to sub-Saharan Africa? Africa. However, we are limited by tional immunization technical advisory A: Our analyses suggest that ex- financial constraints, as our work does groups, which provide evidence-based ternal partners, rather than national not attract much funding. advice to national health authorities on priorities, have driven health research how to implement WHO vaccine poli- in most African countries over the last cies and recommendations. two decades. However, we don’t need We have seen to re-invent the wheel, as much of the Q: How will the conference you are host- a positive change global research evidence is applicable “ ing in Cape Town from 13 to 16 Septem- to Africa. A major priority for new in attitudes towards ber contribute to improving the uptake research in African countries should the use of evidence of scientific evidence in policy-making therefore be implementation research. in health-care in Africa? This type of research helps us under- planning. A: The Cochrane Collaboration stand which health-care interventions holds a colloquium every year. This work in specific contexts and which do ” year will be the first time that Cochrane not, and to test different ways to make will be joined by the four other biggest health-care more effective. African players in evidence-based policy: the countries often fail to make optimal use Q: What are the barriers stopping Afri- Campbell Collaboration, the Johanna of evidence in decision-making, result- can countries from basing their public Briggs Institute, the Guidelines Inter- ing in unnecessary loss of life, reduced health policies and practice on the best national Network and the International quality of life and lost productivity. An scientific evidence? Society for Evidence based Health Care, example, is acquired immune deficiency A: There are several barriers. The to organise the first ever Global Evidence syndrome (AIDS) denialism in South health research field in Africa is char- Summit. We are expecting thousands Africa from 1998 to 2003, characterized acterized by numerous players, diverse of participants, including those from by the refusal to use antiretrovirals for interests, dispersed efforts and uncertain every health-care discipline and from human immunodeficiency virus (HIV) outcomes in relation to its impact on the virtually every country on the continent prevention and treatment. This resulted major health challenges of the continent. of Africa. There is strong evidence that in a reversal of gains in child survival For a better understanding and uptake such interactive, educational meetings, and life expectancy and the loss of a of scientific evidence in health policy- can help health-care workers improve generation of economically active adults making, we need a stronger research their performance. Participants will in their prime. community – research is not well funded have the chance to learn more about or supported in many African countries guideline development, using evidence Q: How are you working to make policy- – and this community needs to forge for emerging global health and social makers in Africa more aware of the need closer links with policy-makers, pro- crises and how the evidence community to base their health-care decisions on the gramme managers and implementers. can overcome denial of clear scientific best available scientific evidence? Sometimes the evidence is difficult for findings. We are really excited about this A: The use of health research in policy-makers to understand. That’s why opportunity to highlight the evidence- decision-making in African countries we provide easy-to-read summaries for based approach to policy and practice in is generally weak. That’s why we advo- them. Sometimes, policy-makers ignore health for countries in Africa. ■
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