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

Decision-makingimplemented on a small scale with substantial managerialand technical support, but may be less effective ifimplemented country-wide with relatively less support.Combining systematic review evidence with other typesof information – frequently policy-makers draw upon a rangeof different types of evidence. For example, a systematicreview of effects might be complemented with costeffectivenessanalysis, or modelling data. Policy-makers willalso wish to consider the political and social acceptability ofthe intervention or policy being considered, and probably alsothe equity implications. Questions such as these mightrequire separate primary data collection research. In healthtechnology assessment, evidence on the effectiveness of thetechnology is typically combined not only with costeffectivenessanalysis but also with consideration of legal,ethical, psychological and social implications 8 . Policy-makersneed to consider carefully how best to combine these differentforms of evidence.Discussion and conclusionsSystematic reviews have great potential to play a key role ininforming policy and decision-making regarding healthsystems. As systematic reviews have become the goldstandard for clinical decision making, we should also strive toensure that they are routinely used as an input into policymaking,acknowledging that other factors, including politicalissues, will also influence policy. In particular, systematicreviews can be helpful in identifying possible negative effectsassociated with a particular reform, so that such possibleeffects can be monitored.The systematic reviews of health systems issuesundertaken to-date are of considerable utility, but we needmore impact evaluations to feed into reviews, more reviews,and more methodological development to make systematicreviews of even greater use to policy and decision-makers. Inparticular methodological development is needed to learnhow best to synthesize research that explores the effects ofcomplex packages of interventions, and to synthesizeevidence regarding processes such as policy andimplementation processes.Given the complexity of health systems, considerable workis involved in assessing the relevance and applicability ofinternational systematic reviews to policy questions beingmade in a particular setting. Moreover, systematic reviewsthemselves are often complex, and require some training interms of how to assess and interpret them. In light of this itseems unrealistic that senior policy-makers will themselvesemploy systematic reviews directly in decision-making.Instead skilled knowledge brokers and analysts are neededwho can help contextualize findings, and marry systematicreview evidence with other types of evidence. To-date verylimited attention has been paid to such functions withinnational health systems and much greater focus on theseroles is needed.Finally, systematic reviews are a useful reminder of howlittle we still know about effective health system strengtheninginterventions. When clear evidence regarding theeffectiveness of a particular policy or intervention is lacking,it is important that policy change is accompanied bymonitoring and evaluation both to avoid possible harms, butalso to contribute to the knowledge base. Systematic reviewscan also be extremely helpful in terms of providing guidanceregarding appropriate study design for such primary research.Sara Bennett is the Manager of the Alliance for Health Policyand Systems Research, an international collaboration based withinWHO, Geneva. She has previously worked as a health systemsresearcher, research manager and in policy roles in low- andmiddle-income countries. She is particularly interested in theinterface between research and policy.Acknowledgements: The author would like to thank JohnLavis and Andy Oxman who have helped immeasurably inshaping her thinking on systematic reviews of health systemsresearch, though they bear no responsibility for the viewspresented here.References1.Travis P et al. Overcoming health system constraints to achieve theMillennium Development Goals. The Lancet, 2004. Freedman L et al.Who’s got the power? Transforming health systems for women andchildren. UN Millennium Project: Task force on Maternal Health and ChildHealth, 2005. Bryce J et al. Programmatic pathways to child survival:results of a multi-country evaluation of Integrated Management ofChildhood Illness. Health Policy and Planning 20 Supplement, 2005,1:i15-i17.2.Straus and Jones. “What has evidence based medicine done for us?”British Medical Journal, 2004, 329:987-988. Muir Gray JA. Evidencebased policy making. British Medical Journal, 2004, 329:988-989.3.Sheldon T. Making evidence synthesis more useful for management andpolicy making. Journal of Health Services Research and Policy, 2005, 10(supplement 1): S1-S5.4.Lagarde M and Palmer N. “Evidence from Systematic Reviews to InformDecision making regarding Financing Mechanisms that Improve Access toHealth Services for poor people”. Alliance for Health Policy and SystemsResearch, WHO, Geneva, 2007.5.The Lagarde and Palmer review included the following study designs:randomized control trials, interrupted time series and controlled before andafter studies.6.Lewin S et al. “Lay health workers in primary and community health care:A Systematic Review of Trials”, 2006, available for download fromhttp://www.who.int/rpc/meetings/LHW_review.pdf7.The authors found 48 articles focused on lay health workers and MCHservices.8.OECD. Health Technology and Decision Making. The OECD health project:OECD Paris, 2005.150 ✜ Global Forum Update on Research for Health Volume 4