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

Decision-makingDelivering evidence to informhealth system strengthening:the role of systematic reviewsArticle by Sara BennettIncreasingly health system bottlenecks are perceived as theprinciple barriers to scaling up the use of critical healthservices and achieving public health goals 1 . While thisperception perhaps started with a concern about lack ofhuman resources, there is now broader recognition of theproblems that multiple health system constraints, such asinequitable systems of health financing, poor quality services,fragmented information systems, and weak accountabilitystructures present. At the time of writing, several new majorinitiatives at the global level, including the UK governmentInternational Health Access Initiative, the Norwegiangovernment Millennium Development Goals 4 and 5Initiative, the Canadian government African Health SystemsInitiative, as well as initiatives from the GAVI Alliance andpotentially the Global Fund to Fight AIDS, TB and Malaria,indicate that there will be substantially increased investmentsin health systems in the near future. But how best to investthese new resources in order to achieve health goals?While there are certain similarities across low- and middleincomecountry contexts in terms of the nature of healthsystem barriers, there is also wide variation in health systemstructures and social values that mean it is not possible tocraft a “one-size-fits-all” solution. Health systemsinterventions will never be able to be reduced to easy toprescribe formulae such as DOTS. National-level policymakersmust craft health policies, plans and systemstrengthening interventions that match their country’s specificneeds. What role can evidence and particularly evidencedrawn from systematic reviews play in ensuring that thenational policies and strategies chosen are effective?During the past ten years Evidence Based Medicine hashad a major impact on how clinicians, managers and policymakersthink about clinical practices 2 . Systematic reviewsSystematic reviews have the advantage of providingfindings based upon the best available evidence, andin being transparent about the source of evidence andhow the evidence has been interpretedhave the advantage of providing findings based upon the bestavailable evidence, and in being transparent about the sourceof evidence and how the evidence has been interpreted.However in the context of health policy and systems researchin low- and middle-income countries, systematic reviewshave only been undertaken to a very limited degree, andalthough there is no data on the topic, it appears that to-datethey have played virtually no role in influencing policy.This paper focuses on the potential contribution thatsystematic reviews could make to policy decisions regardinghealth systems in low- and middle-income countries, and thechallenges to actually using systematic reviews for thispurpose. The paper does not address the nature of demandfor systematic reviews by policy-makers nor their capacity touse and apply systematic review evidence, although both ofthese questions raise complex issues in their own right.The potential for systematic reviews tocontribute to policyFor many questions that health policy and decision-makersmight ask (What is the best way to extend financial protectionto those seeking health care? How have health workersresponded to alternative incentive mechanisms? Whichstrategies are most effective in terms of improving quality ofcare?) a substantial body of evidence exists, but this evidenceis often scattered and not available in a form that decisionmakersfind easy to appraise or use. Systematic reviews ofhealth policy and systems research have the potential toreduce bias in the estimation of the effectiveness of a policyoption by identifying all relevant studies, selecting those thatmeet explicit criteria, appraising their quality, andsynthesizing the results using a transparent process.Systematic reviews reduce the role that chance has to play inestimating effectiveness or cost-effectiveness, and allow moreprecise estimation of the impact of a policy option.Systematic reviews offer considerable advantages to thedecision-maker. First, drawing on an existing systematicreview constitutes a more efficient use of time for researchusers, enabling them to draw upon the research literaturewithout having to comb through it themselves. Second,research users are less likely to be misled by results of asystematic review than a single investigation and thereforecan be more confident about what can be expected.148 ✜ Global Forum Update on Research for Health Volume 4