Strengthening evidence-based healthcare in Africa.

The importance of evidence-based practice in Africa A Collaboration for Evidence Based Healthcare in Africa (CEBHA) has been established with partners from eight sub-Saharan African countries, Ethiopia, Uganda, Rwanda, Burundi, Tanzania, Malawi, Zimbabwe and South Africa. The aim of the Collaboration is to facilitate the provision of patient care based on evidenceinformed decisions using context specific current best evidence; and to build capacity and sustainable structures of Evidence Based Healthcare in Africa. We believe that access to equitable and effective healthcare should be a right for people in all countries. Irrespective of where one lives, the need for valid evidence determining the efficacy of healthcare interventions is essential. Where the unmet needs for health services are most prominent, it is essential to adopt practices that have proven to be beneficial and not harmful or ineffective to ensure scarce resources are not wasted. Incorporating Evidence-Based Health Care (EBHC) into the African context means setting priorities, developing evidence summaries and guidelines and implementing research findings relevant for African countries to support healthcare for all. Contextualising evidence relates to several issues, including the lack of evidence available for an African setting. The effectiveness of an intervention in Africa may be different from that found in studies elsewhere because of factors such as: later presentation, co-infections, malnutrition, higher levels of self-medication and use of traditional remedies, reduced level of resources, including human resources for basic healthcare, and political instability. In addition, effective interventions, as determined by many systematic reviews, may not be available or affordable in most African settings. This means that Africa needs valid and Africa-specific research and that authors of systematic reviews should take this into account by avoiding overgeneralisation when making conclusions. EBHC extends the application of the principles of evidence-based medicine (EBM) as defined by Sackett et al, to all healthcare professionals. Evidence-based public health can be defined as ‘integration of the best available evidence with the knowledge and considered judgments from stakeholders and experts to benefit the needs of a population”. Judged by the number of publications, guidelines, textbooks and references made to the term EBM, few, if any, innovations have probably had a greater impact on healthcare over the last decades than the introduction of the methodologies and practice of EBM. “The Cochrane Collaboration is an enterprise that rivals the Human Genome project in its potential implications for modern medicine” wrote David Naylor in The Lancet. The application of evidence-based methods has become state of the art for clinical and public health decision making in most European countries, Australia and in the USA. Up to now these innovations have not been widely utilised and implemented in African health systems and among the partners of the CEBHA, only South Africa has established centers for EBHC, the South African Cochrane Centre and the Centre for EBHC at Stellenbosch University. Capacity and organisational structures for the development and delivery of contextualised EBHC are lacking in most African countries, but several existing research initiatives and projects for EBHC and policy-making have been identified, among them SURE (Supporting the Use of Research Evidence for policy in African health systems) and REACH (Regional East African Community Health) which have developed tools for evidence-informed policy-making and shown ways of working together internationally. The Effective Health Care Research Consortium (http:// www.evidence4health.org/) has developed evidence summaries relevant to infectious diseases in African contexts. However, for many prioritised areas of public health in low-income and middle-income countries, systematic reviews have not been carried out and there is a lack of contextualised research evidence. 8 The highest rates of child mortality continue to be found in sub-Saharan Africa, where, in 2008, one in seven children died before their fifth birthday. Currently, maternal death rates are almost 200 times higher in sub-Saharan Africa than in high-income countries. 11 Sub-Saharan Africa can increase its pace towards achieving health Millennium Development Goals only if efforts to prevent death and disability are tailored to local conditions and if choices of health interventions and policies are based on solid scientific evidence. At the same time there is a growing technical revolution occurring in Africa, which yields a vast array of opportunities. Internet access and the number of mobile telephones, many of which have internet access, have increased exponentially, with four of five people in Africa now having access to mobile phones.