Combining health and social protection measures to reach the ultra ...

Decision-making
Delivering evidence to inform
health system strengthening:
the role of systematic reviews
Article by Sara Bennett
Increasingly health system bottlenecks are perceived as the
principle barriers to scaling up the use of critical health
services and achieving public health goals 1 . While this
perception perhaps started with a concern about lack of
human resources, there is now broader recognition of the
problems that multiple health system constraints, such as
inequitable systems of health financing, poor quality services,
fragmented information systems, and weak accountability
structures present. At the time of writing, several new major
initiatives at the global level, including the UK government
International Health Access Initiative, the Norwegian
government Millennium Development Goals 4 and 5
Initiative, the Canadian government African Health Systems
Initiative, as well as initiatives from the GAVI Alliance and
potentially the Global Fund to Fight AIDS, TB and Malaria,
indicate that there will be substantially increased investments
in health systems in the near future. But how best to invest
these new resources in order to achieve health goals?
While there are certain similarities across low- and middleincome
country contexts in terms of the nature of health
system barriers, there is also wide variation in health system
structures and social values that mean it is not possible to
craft a “one-size-fits-all” solution. Health systems
interventions will never be able to be reduced to easy to
prescribe formulae such as DOTS. National-level policymakers
must craft health policies, plans and system
strengthening interventions that match their country’s specific
needs. What role can evidence and particularly evidence
drawn from systematic reviews play in ensuring that the
national policies and strategies chosen are effective?
During the past ten years Evidence Based Medicine has
had a major impact on how clinicians, managers and policymakers
think about clinical practices 2 . Systematic reviews
Systematic reviews have the advantage of providing
findings based upon the best available evidence, and
in being transparent about the source of evidence and
how the evidence has been interpreted
have the advantage of providing findings based upon the best
available evidence, and in being transparent about the source
of evidence and how the evidence has been interpreted.
However in the context of health policy and systems research
in low- and middle-income countries, systematic reviews
have only been undertaken to a very limited degree, and
although there is no data on the topic, it appears that to-date
they have played virtually no role in influencing policy.
This paper focuses on the potential contribution that
systematic reviews could make to policy decisions regarding
health systems in low- and middle-income countries, and the
challenges to actually using systematic reviews for this
purpose. The paper does not address the nature of demand
for systematic reviews by policy-makers nor their capacity to
use and apply systematic review evidence, although both of
these questions raise complex issues in their own right.
The potential for systematic reviews to
contribute to policy
For many questions that health policy and decision-makers
might ask (What is the best way to extend financial protection
to those seeking health care? How have health workers
responded to alternative incentive mechanisms? Which
strategies are most effective in terms of improving quality of
care?) a substantial body of evidence exists, but this evidence
is often scattered and not available in a form that decisionmakers
find easy to appraise or use. Systematic reviews of
health policy and systems research have the potential to
reduce bias in the estimation of the effectiveness of a policy
option by identifying all relevant studies, selecting those that
meet explicit criteria, appraising their quality, and
synthesizing the results using a transparent process.
Systematic reviews reduce the role that chance has to play in
estimating effectiveness or cost-effectiveness, and allow more
precise estimation of the impact of a policy option.
Systematic reviews offer considerable advantages to the
decision-maker. First, drawing on an existing systematic
review constitutes a more efficient use of time for research
users, enabling them to draw upon the research literature
without having to comb through it themselves. Second,
research users are less likely to be misled by results of a
systematic review than a single investigation and therefore
can be more confident about what can be expected.
148 ✜ Global Forum Update on Research for Health Volume 4