The work of the Norwegian satellite of the Cochrane Effective Practice and Organisation of Care (EPOC) group

Simon Lewin, Andy Oxman, Susan Munabi-BabigumiraNorwegian Satellite of the Cochrane EPOC group, Norwegian Knowledge Centre for the Health Services, Oslo, Norway

The achievement of health goals, such as the Millennium Development Goals (MDGs), is more likely to be realized through well-informed health policies and actions. However, health policies are often not well-informed by research evidence.This situation has had a number of consequences, including services that are not effective or efficient; effective and cheap interventions not being implemented; services failing to reach those most in need, thereby worsening inequities within health systems; and failure to achieve key health indicators.(1)This contrasts with an evidence-informed approach to health systems strengthening. Evidence-informed health policymaking is an approach to policy decisions that is intended to ensure that such decisions are informed by the best available research evidence.

Research evidence encompasses a variety of different data, including evidence of effectiveness based on randomised controlled trials (RCTs); qualitative evidence on the views and experiences of service users; and information on the cost-effectiveness of different policy options.How research evidence informs policymaking can vary with regard to both the type of decision and the context in which this is made. Nonetheless, evidence-informed policymaking is characterized by the systematic and transparent nature of its access to and appraisal of evidence.Evidence-informed health policymaking is especially important in low- and middle-income countries (LMICs). Saddled with the dual burden of endemic infectious diseases and increasing rates of chronic illnesses, LMICs face difficult health challenges with only limited resources and fragile health systems. There is a need to identify priorities for, and conduct, systematic reviews of interventions relevant to health system questions in these settings. There is also an urgent need to build capacity in LMICs to prepare and support the use of relevant systematic reviews.

The Norwegian Satellite of the Effective Practice and Organisation of Care Group (EPOC) was established in 2006 to support the production of Cochrane reviews that address health systems questions of high relevance to LMICs.EPOC is one of 50 collaborative review groups within the Cochrane Collaboration. It aims to undertake systematic reviews of interventions to improve health care delivery and health care systems across all clinical areas and includes interventions and programmes in the following domains:
- governance (e.g. interventions to reduce corruption in the health sector; methods of consumer involvement in developing health care policy and research)
- financial (e.g. contracting out health services)
- delivery (e.g. the expanded role of pharmacists)
- implementation (e.g. continuing medical education and audit and feedback)(2).

Since 2006, the Norwegian Satellite of the EPOC Group has supported a number of authors to develop Cochrane reviews addressing questions that are relevant and important in their respective settings. Currently, review authors from 12 countries (Argentina, Bangladesh, Cameroon, Chile, China, India, Iran, Kenya, Nigeria, South Africa, Tanzania and Uganda) have developed or are developing Cochrane reviews. These include reviews on the effects of:
- Community mobilization for Safe Motherhood
- Mobile clinics and reproductive health in women
- Interventions to manage dual practice (3)
- Policies to promote facility-based deliveries in LMICs4
- Paying for performance to improve the delivery of health interventions in LMICs (5), and
- Interventions for improving coverage of child immunization in LMICs (6).

In addition to supporting review authors and serving as the editorial base for reviews with a LMIC focus, the Norwegian EPOC satellite contributes to methodological developments relevant to EPOC reviews and to other activities of the review group and the Cochrane Collaboration. This has included the following initiatives:

Structured summaries of reviews for policy makers

The satellite worked with a wide range of collaborators to develop 40 new summaries of systematic reviews that are relevant to decisions about health systems in LMICs. These summaries are intended to improve the ease with which reviews can be understood and interpreted by potential users, including policy makers. The format for these summaries was user-tested widely with policymakers from LMICs, and each summary includes key findings from the review; key information on the studies included in the review; an assessment of the quality of the evidence in the review; and considerations regarding the relevance of the research for LMICs. The summaries, available online at www.support-collaboration.org, could be used to feed evidence on health systems interventions into guideline deliberation processes and policy dialogues.

Tools for policymakers to promote evidence-informed policymaking

The “SUPPORT Tools for evidence-informed health Policymaking (STP)” is a series of articles published in BMC Health Research Policy and Systems. Written for people responsible for making decisions about health policies and programmes and for those who support these decision makers, these tools are intended to help such people ensure that their decisions are well-informed by the best available research evidence, with particular emphasis on the use of systematic reviews. The tools can be downloaded from: www.health-policy-systems.com/supplements/7/S1

Priority topics for new reviews

The satellite continues to develop a list of priority health systems topics for systematic reviews. This list is helpful both in facilitating the production of reviews on important policy questions and also in finding review authors with an interest in undertaking reviews on these topics.In discussing the use of research evidence, Dr Hassan Mshinda of the Ifakara Centre in Tanzania has noted that, “If you are poor, actually you need more evidence before you invest, than if you are rich”. (7) Systematic reviews of global evidence, such as those conducted by EPOC, can provide key information to policymakers in LMICs to inform judgements about the impacts of policies and programmes for investments in health systems strengthening. Further efforts are needed, though, to increase the number of reviews on questions of high relevance to LMICs and to further develop tools to support evidence-informed policymaking.

For more information, visit us at: www.epocoslo.cochrane.org or contact the EPOC managing editor by email: kjetil.olsen@nokc.no

References:
(1) Oxman AD, Lavis JN, Lewin S, Fretheim A: SUPPORT Tools for evidence-informed health Policymaking (STP). 1. What is evidence-informed policymaking. Health Res Policy Syst. 2009, 7(Suppl 1):S1.
(2) Lavis JN, Ross SE, Hurley JE, et al. Examining the role of health services research in public policymaking. Milbank Q 2002; 80: 125–54.
(3) Kiwanuka SN, Kinengyere AA, Nalwadda C, Ssengooba F, Okui O, Pariyo GW. Effects of interventions to manage dual practice (Protocol). Cochrane Database of Systematic Reviews 2010, Issue 3. Art. No.: CD008405. DOI: 10.1002/14651858.CD008405.
(4) Dudley L, Hviding K, Paulsen E. The effectiveness of policies promoting facility-based deliveries in reducing maternal and infant morbidity and mortality in low and middle-income countries (Protocol). Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD007918. DOI: 10.1002/14651858.CD007918.
(5) Witter S, Kessy FL, Fretheim A, Lindahl AK. Paying for performance to improve the delivery of health interventions in low and middle-income countries (Protocol). Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD007899. DOI: 10.1002/14651858.CD007899.
(6) Oyo-Ita A, Nwachukwu CE, Oringanje C, Meremikwu MM. Interventions for improving coverage of child immunization in low-income and middle-income countries (Protocol). Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD008145. DOI: 10.1002/14651858.CD008145.
(7) Lavis JN, Moynihan R, Oxman AD, Paulsen EJ. Evidence-informed health policy 4 - case descriptions of organizations that support the use of research evidence. Implement Sci. 2008; 3:56.