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Apr 8, 2019

Some Random Thoughts: Evidence Synthesis for Health Policy and System (Post 2 / 2019)


One of our esteemed professor, who taught us microbiology at BPKIHS, used to say loud and clear, "If your basic science understanding is shaky, your clinical practice is also going to be shaky." True and this wise statement is very relevant to the current public debate that relates to health education. With mushrooming of medical colleges and with reported poor quality education, this debate is nowadays resonating among Nepalese political elites, policy experts, planners, education experts and all of us citizens. Partly, thanks to Dr. Govinda KC for raising this issue to the forefront of public debate through his persistent fight for quality health education. This brings out one loud question is "how do you we expect any medical professionals supposedly graduated from such a bad school would be able to provide even a satisfactory level health services?" Instead, "wouldn't such health professionals pose a health risk to the population?" Therefore, we all agree in principle and at the personal level that "Quality Health Education of highest standards is the need of the hour if we are to deliver quality health services to all." Our negligence or being complacent at regulating to make sure that we secure high quality in health education would be like carving our own death coffins. So, our way forward to achieve our common vision of "Wealthy Nepal, Healthy Nepal" we must not compromise even an inch in delivering quality education to aspiring health professionals. That is why wise people say, "We get what we plant." Poor seed, poor care would definitely bring a poor harvest.

Our reality:

We can't imagine what goes through a children's mind when s/he is just beginning to explore the world around the Kathmandu valley.  So much chaos, pollution, congested traffic, and suffocation !! All of us complain about it in some way or another. Read about our daily misgivings the way our country is run by politicians and bureaucrats and so on. In a way, we have a galaxy of challenges to face and fix. Sometimes, we wonder how our children have to deal with the future if we are not to fix the ailing Kathmandu valley. This is a huge topic, which I am not going to focus on this blog. However, all in this universe of the complexity of Kathmandu valley that dictates the fate of all, there is one common linkage that we can't ignore and that is our health: our ability to live a healthy life. All that everything around us, be it traffic, nutrition, housing, highway, immigration, legislation, agriculture, security, forest, etc are all interrelated. Therefore, we need to work hard day and night to course correct our path to overall wellbeing and happiness. For this to realize, we need to contribute from all corners and that to the health sector, we need to diagnose the root cause of what is ailing our health system. In this cursory analysis, I am positioning here my argument that if we really want to streamline our Nepal health system, we need to dissect our health education sector and carry out a complete overhaul of health education system. For this, I stress here that we need to build a culture of evidence-based policy decision making with the support of health policy and system research and of course to clearly define a demarcation line between political machine and governance system. 

Realist review in health policy and system research:

Health Policy and System Research (HPSR) is a new term that is a tall order in the global health agenda. In the sea of this new field of system research, one of the approaches of realist review is based on our sound understanding of the local context and its mechanism in the functioning of the health system with the influence of background socio-economic as well as political landscape. The mixture of which and its interplay results in consequences, which could be either positive or negative depending on how well did our homework. In order to untangle the dynamics and its complexity, we need to simplify our understanding of the current health system and for that, we need to lay a solid foundation for the study of health policy and its implementation. We should also remind ourselves again and again that health policy and its implementation research is not an easy task and is said to be of complex nature, which needs perseverance and extraordinary patience to untangle its hidden components, context, and its mechanism. Realist review helps us to unpack, explain and understand the context and its mechanism rather than to determine the effect size of any interventions based on certain policy implementation, so address questions about how, why, for whom, in what contexts and to what extent health systems, programmes and / or policies function, thus providing knowledge useful for its implementation. 

Any complex interventions have multiple components and outcomes that appear to be context-dependent such that some (1) intervention strategies do not bring favorable outcomes. Instead, it could bring change (or not) in the context that matters to the outcomes of interest. Sometimes, (2) we may need to explain how and why context influences outcomes with a complex web of events leading to the final desired outcomes and on top of that, many of times figuring out what constitutes (factors/elements) the context is a challenge (3). To perform reviews of complex health policy and systems interventions, we need to understand the concept of complexity, which is an interplay of multiple, interacting components and non-linear causal pathways/variability in content, context, and mode of delivery as well as the unpredictability of their effects/characteristics (nonlinearity, context dependency, adaptability and interdependence of intervention elements) like there could be intervention complexity/implementation complexity/context complexity/complexity in participant responses. In order to dissect into the complexity, we can institute quasi-experimental studies in health systems evidence synthesis taking into account the issues of external validity and feasibility and cost. However, if we want controlled study then RCT is the gold standard, but external validity would be an issue. In natural experiments, there are "naturally occurring circumstances in which subsets of the population have different levels of exposure to a supposed causal factor, in a situation resembling an actual experiment where subjects would be randomly allocated to groups'. While carrying out such reviews, we need to be cognizance of equity as one of the key principles that should drive health system reviews. Health equity guides us that there is an "absence of avoidable and unfair inequalities in health." For that matter, we need to include equity audits/assessments in the study.  These are particularly essential to inform decision making in the delivery of health care services in a country like Nepal.

We also need to act and for that matter, knowledge production and translation tools are essentially one of the most important components, which we tend to neglect. One of the most important tools is definitely the priority setting exercises, which helps us in framing the review questions, defining the PICOS (population, Intervention, Comparator, Outcome, and Setting) of the reviews and the objectives. Another common but tedious and important tool is to carry out systematic reviews, which address the questions identified in the priority setting meeting/evidence syntheses/scoping review. Once we are able to conduct reviews based on priority setting with a roadmap ahead, we should not forget the development of briefing note (knowledge translation), which will highlight priority issues, synthesized global and context-specific evidence and evidence-based recommendations for action. Finally, we can create a policy opportunity convening of a national policy dialogue (knowledge uptake) sharing the summary report. At the core, we should focus our exercises to secure impact-oriented framework for evidence-informed health policies and practices [in other words - knowledge to practice (K2P)]

Challenges in the context of policy-relevant evidence syntheses:

Key challenges while conducting evidence synthesis in health policy and system research are as follows: (1) limited primary evidence - this is true (what we can do is that we can engage universities and research institutions in this evidence generation activities through students and faculties) (2) access to data such as HINARI Access to Research in Health Programme/Databases (Health Systems Evidence/PDQ - Evidence) / context sensitive and local evidence (which are more important for decision makers) (3) use of local knowledge in policy-relevant reviews - gray literature (government reports) however there are always concern re: quality and validity / WHO programme reporting standards for the design, implementation, M&E of health programmes (4) timeline of reviews - engaging policymakers to generate and maintain an evolving list of policy questions would be beneficial for the country. The list of policy questions to be scheduled and addressed in a timely manner (5) ethical considerations - conflict of interest issue (financial /nonfinancial/institutional) (6) strengthening of capacity for evidence synthesis in HPSR - Global Evidence Synthesis Initiative (GESI), Cochrane, Cambell collaboration, etc., which could be at the institutional level or at the system level.
Fostering the use of evidence synthesis findings in policy and practice:

In our setting such as Nepal, one of the major barriers to health system strengthening and improvement in health outcomes is the inability or poor "know-how" of decision-makers to effectively use syntheses on health systems interventions. Also, compounded by "end-users' attitude and behaviors." Key approaches (insights) to increase the uptake of review findings in health policy-making and health system strengthening are (1) engaging decision-makers (role of knowledge users in evidence syntheses - advisors/expert panel/steering group/team members)/buddying approach (South Africa) (2) enhancing the policy relevance of evidence synthesis (3) improving the format of evidence syntheses (4) using frameworks to support the uptake of reviews - Evidence To Decision (EtD) framework (5) embedding syntheses in complex policy and systems (4 principles - inclusive, rigorous, transparency and accessible).

Anuj in Himalayas

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