Evidence based decision making

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Evidence based decision making

Introduction

Health policy in the broadest sense can be defined as those actions of governments and

other actors in the society that are aimed at improving the health of the populations.

Ideally, there would be a cycle of policy formulation, implementation, and assessment. In

the assessment of policy outcomes, scientific evidence should play an important role9.

One of the dominant themes in health policy and planning today is the need for

interventions to be based on sound evidence of effectiveness. Responsibility for ensuring

that programs are consistent with the best available evidence must be shared between

providers, policy makers and purchasers of services.

Decision makers in health care are increasingly interested in using high-quality scientific

evidence to support clinical and health policy choices. Reliable evidence is essential to

improve health care quality and to support efficient use of limited resources1.

Public health officials and the communities they serve need to: identify priority health

problems; formulate effective health policies; respond to public health emergencies;

select, implement, and evaluate cost-effective interventions to prevent and control disease

and injury; and allocate human and financial resources. Despite agreement that rational,

data-based decisions will lead to improved health outcomes, many public health decisions

appear to be made intuitively or politically2. However, Increased attention is being

directed to the development of methods that can provide valid and reliable information

about what works best in health care.

Among the primary audiences for higher-quality evidence are clinical and health policy

decision makers, including patients, physicians, payers, purchasers, health care

administrators, and public health policymakers. Given the increasing advocacy for health

in the political arena over the past decades, there is an increasing attempt towards

transparency and rationalization of the decision making process in health policy.

Consensus is growing on the interpretation of the role of both broad and specific health

determinants, including health care provision, as well as on priority setting based on the

burden of diseases9. Patients and physicians increasingly seek to combine their personal

beliefs about health care choices with attention to high-quality evidence in making

individual decisions about care. Medical professional societies produce guidelines to

assist physicians and patients in making medical decisions

The growth of medical information and continuing medical educational offerings in the

past few years was huge. Ease of access and availability at any time are advantages of the

World Wide Web. However, the quality of data in general practice clinical information

systems varies enormously. Over the past two decades, national and international

agencies have been systematically collecting a growing body of knowledge in support of

health policy. Their documents typically address issues such as the general health status

of the population and various subgroups, broad and specific health determinants, the

occurrence of specific diseases and the use of health services9.

Evidence based decision making Dr.Mustafa Salih

Rational

As health systems throughout the world decentralize, health patterns shift with aging

populations, and resources available to the health sector continue to decrease, there is a

continuing need to support evidenced-based public health policies and programs in

countries and their communities. Building sustainable programs to strengthen the

capacity in this arena is a delicate process and requires long-term, sustained efforts2.

Public health research deals with the functioning of social systems and their impact on

the health of populations: its outcomes are of interest only if they translate in policies. By

definition, public health research has a vocation to be applicable research.

Although there is a domain of increasing demand for research from decision makers, the

relation between researchers and decision makers is complex made of unsatisfied

expectations on both sides and misunderstanding. It needs to be better understood to be

improved. We also need to improve the effectiveness of the link between research and

decision-making.

the Federal Ministry of Health in Sudan is in the process of undertaking a comprehensive

health system reform that puts into consideration the recent local and international

changes that affect the health system. These changes are political, social, economical and

demographic. The ministry is embarking on preparing the updating of health policies,

strategies, guidelines and regulations as well as rehabilitation and reconstruction of the

health system an aim requiring a solid information base and a comprehensive evidence

based planning. A post-conflict health policy framework and a 25 years strategy for

health have been developed, and a comprehensive health system study is being conducted

at the meantime.

It is time to take actions to promote the culture of evidence based health care in the Sudan

to improve planning and decision making practices. To do this we need to evaluate the

decision making behavior among health directors and policy makers including the

process of decision making, the context, the introduction of information(evidence),

interpretation and application of evidence.

Objectives

General Objective

To assess the evidence based decision making in health care in Sudan, 2003

Specific objectives

To define the sources of information and availability of evidence in the Federal Ministry

of Health, Sudan 2003.

To assess the use of evidence for policy making, planning and decision making by policy

makers and health directors in the Federal Ministry of Health, Sudan 2003.

To determine the information seeking behavior of policy makers and health directors in

the Federal Ministry of Health, Sudan 2003.

To study the link between researchers and policy makers, Sudan 2003

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Literature Review

Evidence-based health care policy

Consumers and providers mention several objectives of health care policy in policy

documents as universal access, comprehensive and uniform benefits, equitable financing,

and value for money, public accountability and freedom of choice. When attempting to

support health policy, it is important to understand how these objectives can be defined,

operationalized and measured. This is by no means straightforward. Therefore, important

obstacles to evidence-based health policy are clear understanding of policy objectives and

the availability of relevant measurement instruments9.

David Sackett's definition of 'evidence based medicine' (EBM) is now well known and

widely accepted. But the phrase 'evidence based health care' (EBHC) is rarely defined.

Evidence based medicine is defined as "An approach to health care practice in which the

clinician is aware of the evidence in support of his/her clinical practice, and the strength

of that evidence." 6. Evidence-based decision-making is centered on the justification of

decisions8. It is known as "The conscientious, explicit, and judicious use of current best

evidence in making decisions about the care of individual patients." 7. In Canada, Prime

Ministers National Forum on Health in 1997 defined it as: The systematic application

of the best available evidence to the evaluation of options and to decision-making in

clinical, management and policy settings.

"Evidence based health care takes place when decisions that affect the care of patients are

taken with due weight accorded to all valid, relevant information." 4

Several things follow from this definition:

1. 'Decisions that affect the care of patients' are taken by managers and health

policy makers as well as by clinicians. EBHC is therefore just as relevant to

managers and policy makers as it is to clinicians.

2. Many factors other than the results of randomized controlled trials contribute to

decisions about the care of patients and may weigh heavily in both clinical and

policy decisions (for instance, patient preferences and resources). This definition

requires that valid, relevant evidence should be considered alongside other relevant

factors in the decision making process. It does not assume that any one sort of

evidence should necessarily be the determining factor in a decision.

3. Before information is used in a decision, an assessment should be made of the

accuracy of the information and the applicability of the evidence to the decision in

question; that is, information should be appraised.

4. 'Information' is deliberately left unspecified; there are many types of information

that may be valid and relevant in particular circumstances. It is not wise to exclude

any particular type of information as long as an appraisal is made of its validity and

relevance and the information is given 'due weight' - neither more nor less.

http://hsc.usf.edu/CLASS/Gene/ebm.htm#Sourse#Soursehttp://hsc.usf.edu/CLASS/Gene/ebm.htm#Sourse#Sourse


Evidence-based policy is not simply an extension of EBM: it is qualitatively different. As

we move from EBM to evidence-based health policy, the decision-making context

changes, shifting from the individual-clinical level to the population-policy level.

Decisions are subject to greater public scrutiny and outcomes directly affect larger

numbers of people, heightening the requirement for explicit justification. This shifting in

decision-making context highlights our current conceptual deficiencies and the limited

attention given to understanding the role that context plays in influencing evidence-based

decisions.

While proponents of EBM have recognized that scientific evidence, by itself, is not

sufficient and needs to be integrated with other types of evidence, they still focus on the

use of the `best' sources of evidence. This has led to the development of numerous

hierarchies of evidence and classification criteria based largely on the sophistication of a

study's design and its methodological rigor. Critics of EBM have countered that these

evidence hierarchies lack their own evidence-base, imposing valuations and preferences

that endeavor to constrain or limit the influence and impact of the full range of potential

evidentiary sources on decision-making 7.

The goal of evidence based decision making (EBDM) may not be for managers and

policy makers to slavishly comply with every scrap of health services research, even

assuming (somewhat unrealistically) that the research clearly resolves the informational

uncertainty. This imperialistic view of the role of research in administrative and policy

decisions seems destined for irrelevance. It is more likely to generate animosity than

collaboration between researchers and decision makers. Rather, successful EBDM may

be no more than recognition of the research and an explanation of the way in which it

was taken into account in the decision. If it was not used, why was it not used? Perhaps

all that is being sought through evidence-based decision-making is a status for science in

decisions that is at least equivalent to the current status of public or interest group

opinion8.

What constitutes evidence?

This question is philosophical, rooted in epistemology and ontology theorizing how we

relate to the world in terms of the creation, interpretation and evaluation of information

and knowledge. This question is also practical, embedded in the fundamental process of

decision-making, explicating support and justification for the decisions we make. The

philosophical and practical aspects of evidence support two distinct orientations to what

constitutes evidence, reflecting fundamentally different relationships between evidence

and context. The first is a philosophical-normative orientation, while the second is a

practical-operational orientation. Therefore, from a philosophical-normative orientation,

what constitutes evidence is largely a function of the quality of the evidence, with the

supposition being that higher quality evidence should lead, in turn, to higher quality

decisions7.

In contrast, the practical-operational orientation to what constitutes evidence is context-

based, with evidence defined with respect to a specific decision-making context. This

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orientation suggests that temporal and contextual variation heavily influence the

determination of what constitutes evidence. Evidence is not static, but rather, is

characterized by its emergent and provisional nature, being inevitably incomplete and

inconclusive. This orientation suggests that evidence is subjective, with different

perspectives producing different explanations for the same decision outcome. Evidence

may simply describe the state of knowledge at a particular time and place This practical-

operational orientation is more aligned with the decision-making sciences, focusing on

how a multitude of factors contribute to a decision outcome. In contrast to the

philosophical-normative orientation, the practical-operational orientation defines

evidence less by its quality, and more by its relevance, applicability or generalisability to

a specific context. This orientation suggests that evidence and context are mutually

inclusive7

Evidence and health systems:

Despite the public health community's agreement that rational decisions based on

comprehensive analysis and good data will lead to improved health outcomes, policy

makers, health officials, program managers, and community organizations seemingly

make health-related decisions intuitively, based on empirical evidence. Some times

decisions are made based on other considerations that include crises, current public

opinion, political interests, or the concerns of organized interest groups2.

Features of a health care system, including the degree of public and/or private financing

and service delivery, and the degree of centralization or decentralization, potentially

constrain or limit policy alternatives. The political attractiveness of a policy issue

influences the degree of formal and informal support, while financial implications can

constrain decision-makers and dictate evidentiary requirements to support a decision7.

As the decision-making context shifts from the individual-clinical level to the population-

policy level, many questions arise: should what constitutes evidence change? Should the

value attributed to different types of evidence change? Should we change how we make

evidence-based decisions?7.

Consensus is growing on the role of broad and specific health determinants, including

health care, as well as on priority setting based on the burden of diseases and the

opportunities to reduce such burden in a cost-effective way. With the increasing number

of advocates for the enhancement of population health in the policy arenas, evidence-

based approaches will provide the information and some of the tools to help with priority

setting9. Evidence-based approaches are prominent on the national and international

agendas for health policy and health research. It is unclear what the implications of this

approach are for the production and distribution of health in populations, given the notion

of multiple determinants in health. It is equally unclear what kind of barriers there are to

the adoption of evidence-based approaches in health care practice.

There will be a demand for intersectoral assessments, in spite of methodological

constraints, especially in the area of health sector reform. Initiators of policy changes in


other sectors might be held responsible for providing the evidence related to health. Due

to limited possibilities for priority setting at the national health care policy level there is a

shift of the responsibility for resource use from the central level to peripheral levels.

Health care providers are encouraged to assume agency roles for both patients and

society and asked to promote and deliver effective and efficient health care. Governments

will have to set up the national framework to facilitate their organization and legal

structure to enhance evidence-based health policy. Treatment guidelines supported by

evidence on effectiveness and efficiency will be one essential element in this process.

National health care policy-making is increasingly evidence-based. Many governments

are supporting agencies for evidence-based health care. At the same time limitations to

priority setting at the political level and insufficient availability of relevant evidence are

apparent. The former can be seen in many health care systems where politicians tend to

deviate from sound evidence-based advice in those cases, where they are asked to

withhold certain treatment programs from patients. Public opinion then provides a

stronger incentive when manipulated well by pressure groups.

We expect a tendency to shift the responsibility for resource allocation in health care

from the central level to peripheral levels, where health care providers are encouraged to

assume agency roles for both patients and society and as such to promote and deliver

costeffective health care. In such settings, health policy deals with organizing the

national framework to use available evidence on such divers areas as diagnostics (e.g.

screening programmes), medical treatment, nursing, and care of patients to its full

extent9.

The government of Sudan adopted the federal system in 1994. Decentralization was

introduced as a system of governance compatible with the needs of the multi-ethnic and

multi-cultural society of Sudan. The country is divided into 26 states and 134 Localities5.

''The system is founded upon a multi-tier government: federal, state and local

governments. The federal level is concerned with policy making, planning, supervision &

co-ordination. The state governments are empowered for planning, policy making and

implementation at state level''5

Federal ministry of Health experienced marked reforms in its general directorates during

the last year. Even though, its systems are still immature to withstand integration of

programmes between different directorates. Both evidence based decision-making and

collaboration needs to be promoted5

Sudan has 26 State Ministries of Health (SMoH), one in each State. The Federal

Ministry of Health (FMoH) is responsible for the development of national health policies,

strategic plans, monitoring and evaluation of health systems activities. The SMoH are

mainly responsible for policy implementation, detailed health programming and project

formulation. The implementation of the national health policy is undertaken through the

district health system based on the primary health care concept5

Health services are provided through different partners including in addition to federal &

state ministries of health, armed forces, universities, private sector (both for profit and not

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for profit) and civil society. However, those partners are performing in isolation due to ill

defined managerial systems for coordination and guidance5.

The history of health research in the Sudan goes back to the end of nineteenth and the

beginning of twentieth centuries, mainly in the areas of tropical diseases and public

health ( at that time prominent and highly learned research and academic institutions

were the sole protectors and guardians of research in the Sudan under the patronage of

Sudan Government3. However, as in many developing countries research in Sudan is

facing many obstacles not only in conducting research, but also in dissemination of

research results to users and policy makers. The contribution of research in changing

practice or policy formulation appears to be minimum or some times nil3

Evidence is used for priority setting , Economic evaluation and public health programmes

assessment in terms of costeffectiveness. The same holds true for many curative

programmes with large financial consequences. Furthermore, it is important to assess

possible discrepancies between the maximum possible outcome as observed in more or

less controlled studies and health benefits as seen in actual practice. Health policy may

benefit from the identification of the determinants of shortages in the process of health

care9.

Two decision-making contexts

We broadly define the decision-making context to include all factors within an

environment where a decision is made. A decision-making context is characterized by its

complexity, comprising both the known and the unknown and the certain and the

uncertain. However, we acknowledge that it is virtually impossible, and likely of limited

utility, to fully account for all contextual factors that might have some potential influence

or impact on a decision

The internal decision-making context accounts for the environment in which a decision

is made and includes factors such as the purpose for the decision-making activity, the role

of participants in a decision-making process and the process employed to arrive at a

decision outcome. Internal contextual factors can be manipulated and controlled, and

explicitly reflect the contextual changes that occur as we move from EBM to evidence-

based health policy. Perhaps the most critical internal contextual factor is related to the

process of decision-making. Process includes both purpose, the `why', and participants,

the `who', but really addresses the structures and mechanisms for `how' decisions are

made7.

The external decision-making context accounts for the environment in which a decision

is applied and includes disease-specific, extra-jurisdictional and political factors. External


contextual factors are fixed, uncontrollable and cannot be manipulated by decision-

makers (at least in the short-term), but clearly play a role in decision-making7.

Disease-specific factors include the geographic, demographic and epidemiologic

characteristics of a disease, each of which can impact on what constitutes evidence and

how that evidence is utilized. Extra-jurisdictional factors refer to the relevant experiences

of other jurisdictions that, while operating in different environments, can impact on what

constitutes evidence and how evidence is utilized for a specific decision-making context.

Both the internal and external decision-making contexts affect what constitutes evidence

and how that evidence is utilized. While few would support decisions based solely on

purpose, process or participants, not many would argue against the significant role that

these internal contextual factors play in any decision. The external decision-making

context can play both a contextual and an evidentiary role, in some situations providing

constraints or limits for a decision, and in other situations providing an evidentiary basis

for supporting or justifying a decision. The better we understand the context, the better

our position to utilize high-quality evidence of all types improve7.

While both evidence and context are fundamental to evidence-based decision-making,

there will always be grey zones blurring a clearly definable relationship between

evidence and context. Therefore it may be less critical how these fundamental

components are defined, and rather more critical how the decision-making context impacts on how evidence is utilized in the development of evidence-based decisions

7.

Introduction of evidence

The introduction of evidence stage refers to the means by which evidence is identified

and the channels through which evidence is brought into the decision-making process.

This stage addresses issues related to the availability and accessibility of evidence,

including a range of evidence dissemination, transfer, diffusion and transmission

activities. The introduction of evidence is based on both the perceived conception of

evidence and the operationalisation of that conception of evidence, subject to both

internal and external contextual factors. (7)

The internal context can directly impact the introduction of evidence into a decision-

making process. The purpose frames the problem, raising different questions. For

example, the purpose could be to make a treatment decision for an individual patient,

develop practice guidelines for clinicians, or develop recommendations for a population-

wide program. As we move from the individual-clinical level to the population-policy

level, the purpose progresses from a focus on efficacy and effectiveness to a focus on

feasibility and implementation issues..

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The process can affect the introduction of evidence through the decision to employ

established evidence hierarchies and whether primary or secondary evidence reviews and

searches will be conducted. The time and effort expended to access evidence and the

extent of dissemination, transfer, diffusion and transmission activities can also affect

what evidence is introduced. Decision-making participants can influence on the

introduction of evidence by expressing personal values, interests, beliefs, or biases

towards different evidentiary sources. As more decision-makers become involved in the

decision-making process, participant variability increases. The role of interpersonal

relationships, potential conflicts of interest, and individual responsibilities for identifying

evidentiary sources, can also be critical.

External contextual factors can indirectly affect the introduction of evidence by altering

the internal decision-making context. For example, variation in service capacity among

urban and rural areas may influence the purpose for, and/or the participants involved in, a

decision-making process, thereby potentially affecting the introduction of evidence.

Furthermore, external contextual factors can directly affect the introduction of evidence if

some of these factors are formally incorporated into the evidence base at the outset of a

decision-making process7.

Identification of pririties: There are a number of sources from which high-priority

questions could be identified. Virtually every clinical guideline,

technology assessment,

systematic review, and consensus report includes a section that lists specific clinical

research priorities. These priorities deserve special attention because of the systematic

and

comprehensive method by which they have been generated.

Finding the Evidence

Over the last decade, an explosion in both the availability and accessibility of information

was observed. With this, we have seen greater recognition of, and attention given to, the

classic economic dilemma between the scarcity of resources and our potentially unlimited

wants, raising difficult resource allocation, rationing and priority setting questions.

Greater demand has been placed on decision-makers at all levels and in all fields to

justify their decisions in response to this dilemma. Decisions are becoming more

transparent, shifting from implicit to explicit methods of decision-making. Evidence-

based decision-making has been proffered as a means to address this growing demand for

explicitly justified decisions7.

Literature Sources

The biomedical literature is huge and growing daily with a wide range of paper journals,

electronic publications, abstracts, posters and books available. There is no single source

or electronic search that will yield all the required evidence. A search for evidence should

begin with a search strategy.

Electronic Databases MEDLINE encompasses information from Index Medicus, Index

to Dental Literature, and International Nursing, as well as other sources of coverage in


the areas of allied health, biological and physical sciences, humanities and information

science as they relate to medicine and health care, communication disorders, population

biology, and reproductive biology. MEDLINE contains bibliographic citations and author

abstracts from over 4,000 journals published in the United States and in 70 foreign

countries. It has 11 million records dating back to 1966. Abstracts are included for about

67% of the records.

HealthInterNetwork

The Health Internet work was created to bridge the "digital divide" in health, ensuring

that relevant information - and the technologies to deliver it - are widely available and

effectively used by health personnel: professionals, researchers and scientists, and policy

makers.

Launched by the Secretary General of the United Nations in September 2000 and led by

the World Health Organization, the Health InterNetwork has brought together public and

private partners under the principle of ensuring equitable access to health information.

The core elements of the project are content, Internet connectivity and capacity building.

Operational research Health services research and outcomes research have made

important contributions toward the effective translation of clinical research discoveries to

clinical practice and health policy. However, observational and other non-experimental

methods may not provide sufficiently robust information regarding the comparative

effectiveness of alternative clinical interventions, primarily because of their high

susceptibility to selection bias and confounding.

Operational research is the application of scientific method to the management of

organised systems. It attempts to provide those who manage organised systems with an

objective and quantitative basis for decision. It is normally carried out by teams of

scientists or engineers, from a variety of disciplines, and often working with people

involved in the organization and with detailed knowledge of it. The subject of operational

research is the decisions that control the organization, with how managerial decisions

could and should be made.

clinical trials The production of high-quality clinical trials will increase significantly

when health care decision makers decide to consistently base their decisions on high-

quality evidence. Research sponsors (public and private) will be motivated to provide the

type of clinical research required by decision makers. Payers and purchasers

can clearly

indicate to the drug and device industry that favorable coverage and payment decisions

will be expedited by reliable. In particular, manufacturers will be motivated to perform

head-to-head comparative trials if these are required to justify payments higher than the

existing less expensive alternatives. Physicians and medical professional organizations

can also increase the degree to which care of individual patients and professional society

clinical policy are guided by attention to reliable evidence.

Interpretation of evidence

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The second stage of the evidence utilization process is the interpretation of evidence

stage. This is where evidence that has been introduced into a decision-making process is

synthesized, evaluated and assessed on its quality and generalisability. During this stage

there is recognition, appreciation and determination of the relevance, appropriateness,

applicability, acceptability and utility of individual sources of evidence for supporting

and justifying a decision7.

The internal decision-making context directly affects the interpretation of evidence stage.

The purpose for the decision-making process can set out the extent to which internal

validity will be evaluated and assessed, in some cases commanding decision-makers to

rely on external reviews, and, in other cases, engaging decision-makers to directly assess

the quality of the evidence themselves. The purpose can also establish limits for assessing

the external validity of the evidence. Consider two purposes: one to develop clinical

practice guidelines and another to develop a population-wide program. The development

of clinical practice guidelines often focuses on the assessment of the internal validity of

the evidence, with the assessment of external validity deferred to the clinician who would

be responsible for interpreting whether or not an individual patient's specific context

appropriately fits within the constraints of the evidence. However, the purpose of

developing a population-wide program would place a much greater focus on the

interpretation of external validity, requiring careful scrutiny of how applicable the

evidence would be to the entire range of individuals making up the target population7.

As in the introduction of evidence stage, the decision-making process can affect the

interpretation of evidence based on the time and effort expended, the extent of

dissemination, transfer, diffusion and transmission activities employed, and the intensity

of the linkages between the research and decision-making communities. These process-

related factors greatly affect the degree to which the internal and external validity of the

evidence can be evaluated and assessed. The use of evidence hierarchies also affects the

interpretation of evidence by explicitly prioritising different types of evidence, with

limited consideration for the particular quality of individual sources of evidence7.

Participants can affect the interpretation of evidence stage for many of the same reasons

as they affect what is introduced as evidence. This includes factors such as which

particular participants ultimately take on the responsibility for interpreting the evidence,

the interrelationships among participants and personal conflicts of interest. Other critical

factors include the participants' receptivity to the evidence, their cognitive and scientific

skills, and the confirmation or challenges that the evidence presents to their existing

beliefs, intuitions and assumptions.

External contextual factors can affect the assessment of internal validity to the extent that

the evidence threshold is extended and more external contextual factors are directly

considered as evidence. Given the different levels of methodological sophistication or

scientific rigor associated with this `evidence', the confidence in the interpretation of the

quality of evidence can thereby be weakened. However external contextual factors, by

their definition, are directly connected to the assessment of the external validity of

evidence, and mark the most obvious and direct relationship between evidence and


context. The more clearly the external decision-making context is understood, the more

clearly the evidence is understood, resulting in improved interpretation of the

generalisability of the evidence to a particular context in which a decision is to be

applied. This reflects the growing recognition of the need to move beyond the usual focus

on internal validity of evidentiary sources to improve methods for interpreting the

external validity of evidence when making evidence-based decisions7.

Application of evidence

The final stage of the evidence utilisation process is the application of evidence. This is

where evidence, that has been introduced and interpreted, is applied to support or justify a

decision. While in the interpretation of evidence stage, individual sources of evidence are

evaluated and assessed, in the application of evidence stage, collective sources of

evidence are weighted, prioritised and/or transformed.

This stage reflects the ultimate influence and impact that individual sources of evidence

have on the decision outcome. However, the impact of evidence is distinguished from the

use of evidence. Attention is given to subtle changes, partial usage and direct or indirect

transformation between the evaluation and assessment of evidence and the weighting and

prioritisation of evidence, with the key being the consistency of evidence utilisation

between the interpretation and application stages. If there is inconsistency between these

stages, what accounts for the transformation? As stated, it is necessary...to give an

account that clarifies how the differing roles of evidence can be weighted at different

contexts and levels of health care".

Again, both internal and external contextual factors have an impact. The decision-making

purpose (e.g. an individual-clinical treatment decision versus population-wide program

development) can set out the level of demand and expectation for evidentiary support and

justification of decision-making. The process can differ regarding the development of, or

requirements for, consensus among decision-makers. As in the previous two stages, if a

decision-making process employs an established evidence hierarchy, the application of

evidence may reflect conformity to that evidence hierarchy, rather than incorporating less

conventional evidentiary sources to support the decision. Decision-making participants

can affect the application of evidence similar to their impact on the other stages, with

personal factors, interpersonal relationships and individual and/or collective conflicts of

interest, directly and indirectly affecting how evidence is applied to a decision.

The external decision-making context also plays an important role in influencing the

application of evidence. This often relates to the ideological compatibility, political

saleability or economic feasibility of a potential evidence-based decision. For example,

the existing political governance or the ruling ideology can affect the application of

evidence at a population-policy level by making certain decisions unacceptable,

necessitating a transformation from an unpopular interpretation of evidence to an

application of evidence that is more politically or ideologically acceptable. The external

decision-making context can also affect the prioritisation of evidence if, for example, a

population has a strong rural component, whereby accessibility and equity issues play an

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important role in determining how different evidentiary sources are weighted and

prioritised to justify a decision7.

Uses of Evidence in Decision Making (1)

While the research and knowledge utilization literatures are often used and cited

interchangeably, they differ from one another in one important way. Whereas research

utilization has a more restricted focus on the use of scientifically produced research,

knowledge utilization is broader in scope, including a range of other sources of data and

information. This distinction is important when considering `evidence utilization' as it

marks a progression from a rather narrow focus on the utilization of scientific research, to

a broader focus on the utilization of knowledge, to an unrestrained focus on the

utilization of scientifically and non-scientifically produced information and knowledge in

support of a decision7.

Several dimensions of utilization have been addressed, including the purposes for

utilization, the utility, degree or extent of utilization, the ultimate impact of utilization,

utilization in relation to beliefs and non-utilisation . It is not entirely clear what

`utilization' actually means stated that "much of the ambiguity in the discussion of

`research utilization'the conflicting interpretations of its prevalence and the routes by

which it occursderives from conceptual confusion". Almost two decades later, added,

with respect to knowledge utilization, that "...it is essential that one be certain of what is

meant by use, and that the concept can be operationalised in a fashion which realistically

provides a basis for evaluation, accountability, and oversight"7.

Many published epidemiologic studies report that particular findings should or could be

used in setting priorities, planning, managing, and evaluating public health. Yet, it is

often difficult to identify whether or how such information actually has been used by

decision makers. Recommendations from epidemiologic investigations frequently are not

implemented, and valid and compelling data that identify major risk factors for important

public health problems go unheeded for decades before having any noticeable effect on

health policy Increasing the use of evidence-based public health in the long-term,

requires the creation of a data-use culture and a behavior change in those involved with

the decision-making environment2.

This pattern underscores the multifactorial and complex nature of decision making in

public health, and documents that considerations other than data, such as political and

philosophical issues (e.g., individual rights versus the effectiveness of regulations to

protect communities), economic, social, ethical, and personal values, influence public

health decisions 2 .

Physician/Patient Decision Making

: Of existing diagnostic or treatment alternatives,

which makes the most sense for an individual patient?

Choosing Plans or Physicians

Which plan or physician is likely to provide high-quality care?


Practice Guidelines

What is the best approach for patients with selected conditions?

Quality Measurement and Improvement

How can evidence-based clinical performance be assessed? Do improvement programs

result in enhanced clinical care?

Product Purchasing and Formulary Selection

How does this product compare with existing alternatives?

Benefit and Coverage Decisions

Should a new service be reimbursed and for which patients?

Organizational and Management Decisions

Does a hospitalist program decrease costs and improve outcomes?

Program Financing and Priority Setting

Which services represent the best value for additional investments?

Product Approval

Should this product be approved and, if so, for which indications?

Factors affecting the use of data

To develop interventions that would increase evidence-based public health, we first

reviewed the literature to identify factors known to affect the use of data in decision

making. We discovered several barriers, including the:

Probabilistic, observational, seemingly inconclusive nature of epidemiologic data (i.e., the quality of epidemiologic evidence)

Failure of decision makers to recognize epidemiologic questions that are relevant to policy issues

Failure of epidemiologists to analyze and frame issues in a policy context for decision makers

Failure of epidemiologists and other technical advisors to package and present data in an understandable and compelling format

Hesitancy of epidemiologists to aid in interpreting findings and to participate actively in the decision-making process

Poor incentive stemming from lack of decision-making authority Failure of HISs to meet the needs of policy makers and program managers in terms

of content, format, timeliness resulting from the non-participation of decision

makers in system design or inadequately designed systems

Lack of trust in the accuracy of HIS data, resulting in decision makers discounting the information and Fear of social or economic consequences

We also found that the type of training that public health professionals receive can

influence the use of data in public health decisions

Many decision makers, technical advisors, and researchers in the health sector have been

trained in programs that emphasize either the use of the scientific method and rationally-

15 | P a g e

based problem-solving techniques for approaching and solving public health problems, or

in programs that focus predominantly on the use of management concepts and tools to

address the organizational, human and financial resource, social, and political

components of health policy and programs. Graduates of either type of program,

however, often lack the full complement of scientific problem-solving and management-

related skills needed to ensure that data are used effectively in the decision process.

Moreover, neither type of program typically provides sufficient training in

communications science, an understanding of which is critical in order for the graduate to

be able to convey data, information, and messages effectively to target audiences for the

purpose of advocating appropriate action.

The Researcher-Decision Maker Relationship

The role that participants in the policy-making process play in defining context is

sometimes overlooked in the literature. Participants constitute a key factor that can

impact both what constitutes evidence and how evidence is interpreted and applied.

Participants can bring personal issues or relationships to the table that might not

otherwise be addressed, altering the purpose and context for decision-making. Even

proponents of EBM have acknowledged that "evidence does not make decisions, people

do7.

Increasingly more common is discussion of the linkages between the `two communities',

researchers and decision-makers. The degree to which linkages exist could clearly have

an effect at the introduction of evidence stage.

Evidence-based health policy-makers face conflicts when attempting to apply the highest

quality evidence possible to population-wide health policy decisions, while at the same

time recognising that evidentiary thresholds may have to be relaxed to incorporate a

broader range of evidentiary sources7 .

Current ideas about evidence-based decision-making tend to focus exclusively on the

direct interaction between researchers and decision makers. This appears to flow from the

customer or client view of the relationship, minimizing the decision makers struggle

with value uncertainty, and focusing on research as a product for delivery to the decision

maker 8 .

In the health system, it is not so simple: researchers and decision makers are rarely

contained within the same organization. In addition, researchers span a continuum,

historically clustered away from the mission-oriented or applied end. Decision makers are

also heterogeneous, consisting of at least the three categories of policy makers, managers,

and service professionals, and they rarely think in terms of researchable questions.

There are few occasions when researchers convene with decision makers

to interact directly, and few mediating mechanisms to indirectly bring their problems and

solutions together8.


Although researchers have difficulty acknowledging it, the sources for the evidence used

by decision makers is rarely at the scientific fact end of the continuum. Stories based

on personal experience, anecdote and myth form the basis of most communications with

decision makers. Moving more to evidence based decision-making will involve

tempering these anecdotes and stories from various interests with facts and evidence

from research. The challenge for evidence-based decision-making is how to make sure

that the ideas, best practices and interventions upon which decision makers act, and

which they receive from knowledge purveyors, contain a more substantial component of

evidence8.

The links between each of these groups are, in fact, relationships between people and/or

organizations. Improvement in evidence based decision-making will involve

strengthening these relationships For instance, decision makers need to find more

effective ways to organize and communicate their priorities and problems, while

researchers and research funders must develop mechanisms to access information on

these priorities and problems and turn them into research activity. Researchers need to

learn how to simplify their findings and demonstrate their application to the health

system in order to communicate better with decision makers and knowledge urveyors.

The knowledge purveyors have to improve their ability to screen and appraise

information to sort the facts from the stories. Decision makers and their organizations

need to improve their capacity to receive such appraised and screened information and to

act upon it developing receptor capacity8 .

Getting the evidence, as represented by health services research, into decision-making

involves

multiple steps and is not only a matter of direct linkage between decision makers and

researchers. Each of the steps involves improving relationships and communication

across the four groups in the health sector, and that evidence-based decision-making is a

virtuous cycle and any weak link in the chain has the capacity to interrupt the optimal

flow of research into decision making.

In the shift from an individual-clinical to a population-policy level, the decision-making

context becomes more uncertain, variable and complex. Because although decision

makers are requesting more and more that researchers be their advisors, nevertheless this

relation is complex, made of unsatisfied expectations on both sides and

misundertsanding;

Why do we need to improve the effectiveness of the link between research and

decision making?

Because research has become a domain of increasing demand from decision makers;

Because, by definition, public health research has a vocation to be applicable research.

Public health research deals with the functionning of social systems and their impact on the health of populations: its outcomes are of interest only if they

translate in policies

From decision to research:

17 | P a g e

Translation means to explain the decision context, so as to adapt the research agenda and anticipate on the reactions of different constituencies.

From research to decision:

Translation means to explicit to the decision maker the way his or her demand has been transformed.

Methodology

Study design

Descriptive cross sectional study to assess evidence based decision making in health,

Sudan 2003.

Study area

Sudan is the largest country in Africa. It has an area of 2.5 million km2. It is

characterized by a strategic geographical location, that links the Arab world to Sub

Saharan Africa, and it shares its borders with 9 countries, where the Sudanese population

and those of the neighbouring countries move freely across these borders. The

environment ranges from damp rainy in the south, to desert in the northern areas. The

population of the country is estimated at 32 million (projected from 1993 census). The

population is unevenly distributed in the 26 States, the majority are concentrated in 6

States of the Central Region with a mean population density of 10 people per square

kilometres, increasing to 50 at the agricultural areas. Natural disasters and the conflict

resulted in high rates of rural-urban migration reaching 15%. The growth rate is 2.6%,

indicating that the population doubles every 27 years


Sudan suffers from acute and complex health problems. The cycle of poverty,

malnutrition and loss of productivity exposes at risk populations to debilitating and

serious diseases such as malaria, Tuberculosis (TB), malnutrition, diarrhoea, and Acute

Respiratory Infections (ARI). The expansion of health facilities has not matched the

growth in population over the years, and the war has destroyed many previously

operating health facilities. Ineffective coverage is manifested in lack of infrastructure,

inadequate drugs and medical equipment, and lack of skilled health personnel. Chronic

conflict has stretched the countrys social service institutions including health, directly or

indirectly. The war has a devastating effect on delivery of health care services, in a

country already plagued with draught and epidemics. Lack of access to populations and

the limited infrastructure has impeded the ability of the government, as well as the non-

state health actors to provide services and assistance.

Communicable diseases dominate the health scene with high vulnerability to outbreaks.

In addition, the double burden of diseases further creates a heavy load, to which the

health system is not equipped to combat. Malaria is now considered endemic throughout

the country and continues to feature as the major health problem in Sudan causing 7.5 8

million episode and 35,000 40,000 deaths per year. Diarrhoea and ARI prevalence

rates are 28% and 17% among children under-five respectively, and diarrhoea prevalence

reaches 40% in some States. The annual risk of infection for tuberculosis equals 1.8 %,

and this indicates that for every 100,000 there are 90 infective cases5.

Health Research in Sudan

Priority setting

At least thirty priority research problems were identified in each state using the

WHO selection criteria. Ten were epidemiological, ten biomedical and ten health

system research problems.

A National Health Research Conference was convened in September 2000. It

endorsed the national priority health research problems according to rank and

recommended capacity strengthening for health research, commitment to the priority

research agenda, conduction of operational research and utilization of research

results.(3)

Study population

Sample frame and sampling techniques

Methods of data collection

Results and discussions

Results

19 | P a g e

Table No1 Definition of priority policy questions by FMOH directorates and

programmes

Defined policy questions No of Directorate

Yes 16 (76.1%)

No 5 (23.9%)

Total 21 (100%)

Table No 2 Availability of internet services for FMOH directorates and

programmes 2003

Availability on internet services No of Directorate

Available all time 8 (38%)

Available some times 12 (57%)

Not available 1 (05%)

Total 21 (100%)

Table No 3 Utilization of internet services by FMOH directors 2003

Use of internet services No of Directors

Use daily on regular base 11 (52.3%)

Many times per weeks 7 (33.3%)

Some times 2 (9.5%)

Dont use 1 (4.7%)

Total 21 (100%)

Table No 4 main reasons of using internet services by FMOH directors 2003

Use of internet services No of Directors

Search 20 (95.2%)

Communication 13 (61.9%)

Table No 5 knowledge about literature sources in the www by FMOH directors

2003

Knowledge No of Directors

Good knowledge 13 (61.9%)

Little knowledge 5 (23.8%)

Dont know 3 (14.2%)

Total 21 (100%)

Table No 6 Conduction of research by FMOH directorates and programmes 2003

Conduction of research No of Directorates


Yes 11 (52.3%)

No 10 (47.6%)

Total 21 (100%)

Table No 7 No of researches Conducted by FMOH directorates and programmes

2002-2003

No of research No of Directorates

1-2 researches 5 (23.8%)


More than 5 researches 2 (9.5%)

No research conducted 11 (52.3%)

Total 21 (100%)

Table No 7 No of researches Conducted by directorates and programmes in

collaboration with research institutes outside FMOH 2002-2003

No of research No of Directorates



More than 5 researches 1 (4.7%)

No research conducted 14 (66.6%)

Total 21 (100%)

Table No 8 Receiving research reports from research institutes outside FMOH by

directorates and programmes 2003

Receiving reports No of Directorates

Regularly 1 (5%)

Sometimes 11 (52.3%)

Not receiving 8 (40%)

Total 20 (100%)

Table No 9 Use of research results for policy by FMOH directorates and

programmes 2003

Use results for policy No of Directorates

Yes 13 (61.9%)

No 8 (38%)

Total 21 (100%)

11 | P a g e

Table No 10 Reasons of not Using research results for policy by FMOH directorates

and programmes 2003

Reason No of Directorates

No need to use it 0 (00%)

Available information is not

enough to build a decision

5 (62.5%)

Poor quality of available research 0 (00%)

Dont know how to use it 0 (00%)

Others 3 (37.5%)

Total 8 (100%)

Table No 11 Type of research conducted by research institutes, Sudan 2003(n=21)

Type No of institutes

Epidemiological research 4 (19%)

Health system Research 3 (14.2%)

Clinical research 9(42.8%)

Basic research 5 (23.8%)

Different types 2 (9.5%)

Table No 12 Areas of work of research institutes, Sudan 2003(n=21)

Area of work No of institutes

Communicable diseases 3

Non communicable diseases 8

Health economics 1

Bio medical research 2

other 6

Table No 13 Targeted audiences for research institutes, Sudan 2003(n=21)

Targeted audience No of institutes

MOH 16

Researchers 19

Physicians 19

Donors 11

Others 5

Table No 14 Methods of dissemination of research results by research institutes,

Sudan 2003(n=21)

Method of dissimination No of institutes


International journal 17

Local periodical 13

Seminar 16

Other 1

Table No 15 Sending research reports by research institutes to policy makers,

Sudan 2003(n=21)

Sending research reports No of institutes

Yes 16

No 5

Total 21

1. S R. Tunis, B. Stryer, C. M. Clancy,"Increasing the Value of Clinical Research

for Decision Making in Clinical and Health Policy" JAMA. 2003;290:1624-1632.

Tunis SR Stryer DB, Clancy CM.

2. Pappaioanou M, Malison M, Wilkins K, Otto B, Goodman RA, Churchill RE,

White M, Thacker SB ( Strengthening capacity in developing countries for

evidence-based public health: the data for decision-making project.) , Social Science

& Medicine Volume 57, Issue 10 , November 2003 , Pages 1925-1937

3. Mapping survey

4. (Dr Nicholas Hicks Department of Public Health and Health Policy Oxfordshire

Health Authority)

5. strategy

5. Evidence Based Medicine Working Group at McMaster University, Canada 6. BMJ, 312:71-2,1996 7. Mark J. Dobrowa, Vivek Goelb and R. E. G. Upshurc Evidence-based health

policy: context and utilisation Social Science & Medicine Volume 58, Issue 1 ,

January 2004, Pages 207-217

8. HEALTH SERVICES

RESEARCH AND...

Evidence-Based Decision-Making

https://hin-sweb.who.int/_base(http:/www.sciencedirect.com/):/science?_ob=JournalURL&_cdi=5925&_auth=y&_acct=C000049744&_version=1&_urlVersion=0&_userid=977298&md5=f6e59cff490a83beb0012989df88ea7bhttps://hin-sweb.who.int/_base(http:/www.sciencedirect.com/):/science?_ob=JournalURL&_cdi=5925&_auth=y&_acct=C000049744&_version=1&_urlVersion=0&_userid=977298&md5=f6e59cff490a83beb0012989df88ea7bhttps://hin-sweb.who.int/_base(http:/www.sciencedirect.com/):/science?_ob=IssueURL&_tockey=%23TOC%235925%232003%23999429989%23452175%23FLA%23display%23Volume_57,_Issue_10,_Pages_1771-2012_(November_2003)%23tagged%23Volume%23first%3D57%23Issue%23first%3D10%23Pages%23first%3D1771%23last%3D2012%23date%23(November_2003)%23&_auth=y&view=c&_acct=C000049744&_version=1&_urlVersion=0&_userid=977298&md5=9cc541446b5af3e30a28070aced5db7bhttp://www.bmj.com/https://hin-sweb.who.int/_base(http:/www.sciencedirect.com/):http:/www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6VBF-48V7W7S-1&_coverDate=01%2F31%2F2004&_alid=126978954&_rdoc=1&_fmt=&_orig=search&_qd=1&_cdi=5925&_sort=d&view=c&_acct=C000049744&_version=1&_urlVersion=0&_userid=977298&md5=9ad71bdef9260e021b04bdff859b17cf#affb#affbhttps://hin-sweb.who.int/_base(http:/www.sciencedirect.com/):http:/www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6VBF-48V7W7S-1&_coverDate=01%2F31%2F2004&_alid=126978954&_rdoc=1&_fmt=&_orig=search&_qd=1&_cdi=5925&_sort=d&view=c&_acct=C000049744&_version=1&_urlVersion=0&_userid=977298&md5=9ad71bdef9260e021b04bdff859b17cf#affc#affchttps://hin-sweb.who.int/_base(http:/www.sciencedirect.com/):/science?_ob=JournalURL&_cdi=5925&_auth=y&_acct=C000049744&_version=1&_urlVersion=0&_userid=977298&md5=f6e59cff490a83beb0012989df88ea7bhttps://hin-sweb.who.int/_base(http:/www.sciencedirect.com/):/science?_ob=IssueURL&_tockey=%23TOC%235925%232004%23999419998%231%23FLA%23display%23Volume_58,_Issue_1,_Pages_1-221_(January_2004)%23tagged%23Volume%23first%3D58%23Issue%23first%3D1%23Pages%23first%3D1%23last%3D221%23date%23(January_2004)%23&_auth=y&view=c&_acct=C000049744&_version=1&_urlVersion=0&_userid=977298&md5=432e31aa43914d756b4feb5f86f6d9de

13 | P a g e

9. The evidence-based approach in health policy and health care delivery Social

Science & Medicine

Volume 51, Issue 6 , 15 September 2000 , Pages 859-869 Louis W. Niessen,

,

Els W. M. Grijseels and Frans F. H. Rutten

Institute of Medical Technology Assessment, Erasmus University, Rotterdam, The

Netherlands

Health Research in Sudan

Since the beginning of the 20th

Century, health research has been a very important factor

in the development of Sudan health services and in the shaping of health policy. The need

for it was seen by the colonial administration as early as 1903 when the Welcome

Tropical Research Laboratories (WTRL) were established as part of Gordon Memorial

College (GMC). This was not only a significant development in the medical history of

the country, but also an important one on a continent-wide basis. The revealing objectives

of the WTRL and their multidisciplinary approach were the most appropriate way of

successfully tackling the health problems of a vast country like the Sudan. Their

contributions to health science in that era of pioneering health research were

acknowledged by commemorating the name of their second director, A J Chalmers, in the

Chalmers Medal of the Royal Society of Tropical Medicine and Hygiene (RSTMH). His

most important contributions were in tropical diseases notably schistosomiasis. Chalmers

in Khartoum confirmed Leipers discovery of the snail intermediate host in Ismailia in

1915. Christopherson in 1919 successfully treated the disease in Khartoum Civil

Hospital using potassium antimony tartrate. These were probably the most significant

contributions made to health science and research by two members of the Sudan Medical

Service (SMS).

A land mark in the history of medicine in the country was the establishment of the

Kitchener School of Medicine (KSM) in 1924, as the first medical school in tropical

Africa, to serve, in conjunction with WTRL, as a great civilizing factor in north-east

Africa.

https://hin-sweb.who.int/_base(http:/www.sciencedirect.com/):/science?_ob=JournalURL&_cdi=5925&_auth=y&_acct=C000049744&_version=1&_urlVersion=0&_userid=977298&md5=f6e59cff490a83beb0012989df88ea7bhttps://hin-sweb.who.int/_base(http:/www.sciencedirect.com/):/science?_ob=JournalURL&_cdi=5925&_auth=y&_acct=C000049744&_version=1&_urlVersion=0&_userid=977298&md5=f6e59cff490a83beb0012989df88ea7bhttps://hin-sweb.who.int/_base(http:/www.sciencedirect.com/):/science?_ob=IssueURL&_tockey=%23TOC%235925%232000%23999489993%23197335%23FLA%23display%23Volume_51,_Issue_6,_Pages_787-989_(15_September_2000)%23tagged%23Volume%23first%3D51%23Issue%23first%3D6%23Pages%23first%3D787%23last%3D989%23date%23(15_September_2000)%23&_auth=y&view=c&_acct=C000049744&_version=1&_urlVersion=0&_userid=977298&md5=9edafa631120b0f959da184bb092678chttps://hin-sweb.who.int/http:/www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6VBF-40D5X4K-7&_user=977298&_coverDate=09%2F15%2F2000&_fmt=full&_orig=search&_qd=1&_cdi=5925&view=c&_acct=C000049744&_version=1&_urlVersion=0&_userid=977298&md5=52bfa95df1d6371d462f14128d01da26&ref=full#m4.cor*#m4.cor*https://hin-sweb.who.int/spool/common_files/[email protected]


In 1927 the Stack Medical Research Laboratories (SMRL) were established and formed

the bacteriological wing of WTRL. The reorganization of the services dealing with

scientific research in 1935 made the SMRL the official research organ of the SMS and

the WTRL became the Wellcome Chemical Laboratories (WCL). By the late 1930s the

research complex of the SMS had a tripartite structure: SMRL, WCL and the

Entomological Laboratories. This reshaping of health research administration marked the

beginning of a new epoch of health research in the Sudan, which reached its zenith in the

1940s. A series of officially directed applied research projects were designed around the

public health problems of the country. These are:

1. Malaria control and Anopheles gambiae entomological survey in the

Gezira.

2. The first Yellow fever serological survey in Africa (southern and

western Sudan).

3. The first employment of the yellow fever 17D vaccine in an epidemic in

Africa

(Nuba Mountains epidemic).

4. Research on Kala-azar, cerebrospinal meningitis, enteric fever,

smallpox, rabies,

typhus fever, diphtheria and onchocerciasis.

5. The establishment of a vaccine institute in 1937 for the local production

of smallpox,

TAB, cholera and rabies vaccines.

6. Outstanding research on the transmission and chemotherapy of

leishmaniasis

Established phlebotomus orientalis as the vector and sodium antimony

gluconate

(pentostam) as a satisfactory therapeutic agent.

15 | P a g e

On account of outstanding contributions to tropical medicine and medical entomology

another two members of SMS were awarded the Chalmers Medal of the RSTMH, Robert

Kirk in 1943, and DJ Lewis in 1953

4.1.1.2 Post-Independence:

The creation of a Sudanese Ministry of Health (MOH) in 1949 during the transitional

period resulted in the Sudanization of senior posts and Robert Kirk was succeeded by

MA Haseeb as Assistant Director for Research in charge of SMRL. Simultaneously with

the start of Sudanese research leadership, some outstanding developments took place in

health research.

Both Hasseeb and Satti, the first nationals to pioneer research in the country, were

awarded the Shousha Foundation Prize for outstanding contribution to medical education

and research in the Sudan in 1963 and 1970, respectively:

1952 : A unified policy for the training of laboratory assistants in the North

and South was

designed and the School for Laboratory Assistants at SMRL became a

WHO collaboration training centre.

1953 : The Sudan Medical Journal was launched as the official organ of Sudan

Medical

Association and a venue for research communication. The journal,

however, has

faced financial difficulties periodically.

1954 : The initiation of Sudanese Laboratory Technicians training.

1956 : WHO assistance to deal with major public health problems.

1960 : United States Naval Medical Research Unit Number Three (NAMRU-

3) started a

five-year investigation to elucidate the epidemiology of visceral

leishmaniasis.


1963 : Sattis (Hasseebs successor) discovery of a new experimental host for

leishmaniasis, the bush baby Galago senegalensis senegalensis.

1963 : Design of a concerted programme for postgraduate training of Sudanese

researchers

in Britain to cater for the broadening base of health research activities.

1963 : The Faculty of Medicine, University of Khartoum (U of K) started to

grant postgraduate research degrees in the health sciences.

1970 : The inauguration of the National Public Health Laboratories

incorporating SMRL,

WCL, Entomological Laboratories together with accommodating the

Departments

of Pathology and Microbiology of the Faculty of Medicine, University

of Khartoum.

Further developments took place in the 1970s towards reorganization of health research

and scientific research in the country:

1970 : The National Council for Research was established with five

specialized research

sub-councils: Agricultural, Animal Resources, Economic and Social,

Industrial Research Center and Medical Research Council (MRC)

1971 : A Ministry of Higher Education and Research was created.

1972 : The MRC established the Institute for Tropical Medicine and the

Hospital for

Tropical Medicine.

1976 Gezira Faculty of Medicine and later Juba and other medical schools

were

established with new concepts of medical education

1978 : The Postgraduate Medical Studies Board in the Faculty of medicine,

University of Khartoum awards post graduate clinical degrees.

Research is considered as an integral component of the degree and a

17 | P a g e

thesis is a prerequisite for its award.

In 1991 the National Council for Research of the Ministry of Higher Education and

Research became the National Research Centre and the sub-councils were renamed,

institutes. Within the health sector, the Institute for Tropical Medicine continued to exist.

Link between evidence and decision

Access to the online evidence base in general practice: a survey of the Northern and

Yorkshire Region. Wilson P, Glanville J, Watt I. Health Info Libr J. 2003

Sep;20(3):172-8

AIMS: To assess the awareness and use of NHSnet within general practice. To

investigate the presence of skills necessary to maximize the benefits of NHSnet

connections. METHODS: Postal survey of general practice staff in the Northern and

Yorkshire Region. RESULTS: At least one completed questionnaire was obtained from

65% of the general practices surveyed, and the individual response rate to the general

practice survey was 44%. Ninety per cent of all respondents reported that their practice

was connected to the NHSnet, with 59% of respondents reporting that they use NHSnet at

least once a week. Although NHSnet was used to search for research information or

guidance, all respondents in this survey still reported greater access to and use of paper-

based information resources. Respondents indicated that they still needed further training

on how to use NHSnet (42%), how to search the Internet (31%) and how to search

electronic databases such as medline (49%). CONCLUSIONS: Since our 1999 survey,

reported NHSnet connectivity has increased greatly, with a majority of respondents

reporting that they use NHSnet at least once a week. Although encouraging, this level of

usage suggests that using the Internet/NHSnet to find research has yet to become a core

activity in general practice.

display knowledge of the sources of relevant epidemiological and demographic data and

its interpretation order to apply and underpin

Khartoum

MEMORANDUM OF UNDERSTANDING

ON THE PROPOSED SITUATION ANALYSIS

OF HEALTH RESEARCH IN THE SUDAN

1.INTRODUCTION: There is a gross imbalance in health research in developing countries including Sudan. This issue

needs to address to find a possible solution for the existing inequities in opportunities and resources in

health and health research . During the last decade Sudan has initiated a mechanism to develop health


research including capacity building, organizational mechanisms, documentation and formulation of

priorities.

2.HEALTH RESEARCH STRUCTURE AND DEVELOPMENT:

2.1 HISTORICAL PROSPECTIVE:

2.1.1. Pre-Independence: Since the beginning of the 20

th Century, health research was a very important factor in the

development of Sudan health services and in the shaping of health policy. The need for it was seen by

the colonial administration as early as 1903 when the Welcome Tropical Research Laboratories (WTRL)

were established as part of Gordon Memorial College (GMC). This was not only a significant

development in the medical history of the country, but also an important one on a continent-wide basis.

The revealing objectives of the WTRL and their multidisciplinary approach were the most appropriate

way of successfully tackling the health problems of a vast country like the Sudan. Their contributions to

health science in that era of pioneering health research were acknowledged by commemorating the name

of their second director, A J Chalmers, in the Chalmers Medal of the Royal Society of Tropical

Medicine and Hygiene (RSTMH). His most important contributions were in tropical diseases notably

schistosomiasis. Chalmers in Khartoum confirmed Leipers discovery of the snail intermediate host in

Ismailia in 1915. Christopherson in 1919 successfully treated the disease in Khartoum Civil Hospital

using potassium antimony tartrate. These were probably the most significant contributions made to

health science and research by two members of the Sudan Medical Service (SMS).

A land mark in the history of medicine in the country was the establishment of the Kitchener

School of Medicine (KSM) in 1924, as the first medical school in tropical Africa, to serve, in

conjunction with WTRL, as a great civilizing factor in north-east Africa.

In 1927 the Stack Medical Research Laboratories (SMRL) were established and formed the

bacteriological wing of WTRL. The reorganization of the services dealing with scientific research in

1935 made the SMRL the official research organ of the SMS and the WTRL became the Wellcome

Chemical Laboratories (WCL). By the late 1930s the research complex of the SMS had a tripartite

structure: SMRL, WCL and the Entomological Laboratories. This reshaping of health research

administration marked the beginning of a new epoch of health research in the Sudan, which reached its

zenith in the 1940s. A series of officially directed applied research projects were designed around the

public health problems of the country. These are:

1. Malaria control and Anopheles gambiae entomological survey in the Gezira.

2. The first Yellow fever serological survey in Africa (southern and western Sudan).

3. The first employment of the yellow fever 17D vaccine in an epidemic in Africa

(Nuba Mountains epidemic).

4. Research on Kala-azar, cerebrospinal meningitis, enteric fever, smallpox, rabies,

Typhus fever, diphtheria and onchocerciasis.

5. The establishment of a vaccine institute in 1937 for the local production of smallpox,

TAB, cholera and rabies vaccines.

6. Outstanding research on the transmission and chemotherapy of leishmaniasis

Established phlebotomus orientalis as the vector and sodium antimony gluconate

(pentostam) as a satisfactory therapeutic agent.

On account of outstanding contributions to tropical medicine and medical entomology another two

members of SMS were awarded the Chalmers Medal of the RSTMH, Robert Kirk in 1943, and DJ

Lewis in 1953

2.1.2 Post-Independence:

The creation of a Sudanese Ministry of Health (MOH) in 1949 during the transitional period resulted in

the Sudanization of senior posts and Robert Kirk was succeeded by MA Haseeb as Assistant Director for

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Research in charge of SMRL. Simultaneously with the start of Sudanese research leadership, some

outstanding developments took place in health research:

1952 : A unified policy for the training of laboratory assistants in the North and South was

designed and the School for Laboratory Assistants at SMRL became a WHO

collaboration training centre.

1953 : The Sudan Medical Journal was launched as the official organ of Sudan Medical

Association and a venue for research communication. The journal, however, has

faced financial difficulties periodically.

1954 : The initiation of Sudanese Laboratory Technicians training.

1956 : WHO assistance to deal with major public health problems.

1960 : United States Naval Medical Research Unit Number Three (NAMRU-3) started a

five-year investigation to elucidate the epidemiology of visceral leishmaniasis.

1963 : Sattis (Hasseebs successor) discovery of a new experimental host for

leishmaniasis, the bush baby Galago senegalensis senegalensis.

1963 : Design of a concerted programme for postgraduate training of Sudanese researchers

in Britain to cater for the broadening base of health research activities.

1963 : The Faculty of Medicine ,University of Khartoum (U of K) started to grant

postgraduate research degrees in the health sciences.

1970 : The inauguration of the National Public Health Laboratories incorporating SMRL,

WCL, Entomological Laboratories together with accommodating the Departments

of Pathology and Microbiology of the Faculty of Medicine, University of Khartoum.

Both Hasseeb and Satti, the first nationals to pioneer research in the country, were awarded the Shousha

Foundation Prize for outstanding contribution to medical education and research in the Sudan in 1963

and 1970, respectively.

Further developments took place in the 1970s towards reorganization of health research and scientific

research in the country:

1970 : The National Council for Research was established with five specialized research

sub-councils: Agricultural, Animal Resources, Economic and Social, Industrial

Research Center and Medical Research Council (MRC)

1971 : A Ministry of Higher Education and Research was created.

1972 : The MRC formulated five priority research areas: Tropical diseases, childhood

diseases, malnutrition, physiological norms and control of tuberculosis, and adopted

a system of short- term project funding.

1972 : The MRC established the Institute for Tropical Medicine and the Hospital for

Tropical Medicine.

1976 Gazira Faculty of Medicine and later Juba and other medical schools were

established with new concepts of medical education

1978 : The Postgraduate Medical Studies Board in the Faculty of medicine, University of

Khartoum awards post graduate clinical degrees. Research is considered as an

integral component of the degree and a thesis is a prerequisite for the award of the

degree.

In 1991 the National Council for Research of the Ministry of Higher Education and Research became

the National Research Centre and the sub-councils were renamed, institutes. Within the health sector,

the Institute for Tropical Medicine continued to exist.

2.2. RECENT DEVELOPMENTS: RESUME OF CURRENT NATIONAL HEALTH

RESEARCH STRUCTURE:

2.2.1. The Research Directorate: In 1998 the FMOH changed its Health System Research Unit established in 1996 to the Research

Directorate (RD) to be responsible to the Under-Secretary. The RD has four units: Administration and


Finance, Training, Documentation and Information and Research Implementation. Is guided by a multi-

disciplinary Research Council (RC). The Research Council, consist of all directorates of the FMOH,

States MOH, medical schools, health institutions, individual researchers, healthrelated sectors, NGOs

and the community, is charged with the objectives of laying down of the following:

General policy, work plans and follow-up of their implementation.

Principles of collaboration between all sectors involved in health research.

To ensure maximal use of meager financial and manpower resources, the RC at its first meeting in

January 2000 emphasized the importance of priority setting for health research.

2.2.3. Achievements of the RD to-date:

Preparation of the priority research agenda in the country. At least thirty priority research

problems were identified in each state using the WHO selection criteria. Ten were

epidemiological, ten biomedical and ten health system research problems.

A National Health Research Conference was convened in September 2000, agreed upon the

national priority health research problems according to rank and recommended capacity

strengthening for health research, commitment to the priority research agenda, conduction of

operational research and utilization of research results.

A Data Base for Health Research was started in 2000 as a collaborative project to provide

information about health related colleges, research institutes and health research units at the

FMOH and in the states. Information on research institutions and health research abstracts since

1940 was collected. Still incomplete, the database now contains 3,000 abstracts available in

electronic form (CD-ROM). A research manual for training in research methodology was published in English and Arabic,

many training courses were conducted and the research methodology training was incorporated in

the curricula of the paramedical schools.

State Research Units were established for capacity strengthening in 8 states: Khartoum, Gezira,

White Nile, Kassala, Red Sea, River Nile, North Kordofan and North Darfur.

Seventeen Monthly Seminars for proposal review and presentation of research results were

conducted on various topics.

Recently a new Ministry of Science and Technology was created which implies an expected

restructuring and strengthening of the organization of scientific research in the country.

3.MAJOR HEALTH RESEARCH INSTITUTIONS PROFILES:

The names and addresses of the main health research organizations in the country, governmental and

non-governmental, are depicted in the following table:

4. DESCRIPTION OF THE PROPOSED STUDY: 4.1. JUSTIFICATION:

All health indicators show that endemic, communicable and infectious diseases are considered among

major health problems in the Sudan. Sudan is characterized by diversity of health problems. These

problems are further enhanced by the upheaval due to war displacement, famine, refugees and the

changing pattern of diseases with the emergence of diseases of affluence particularly in major cities. All

these need to be addressed through well-orchestrated health research mechanisms.

Numerous lessons could be learnt from the review of the history of health research in the Sudan.

It is hoped that, based on the outcome of this exercise, a strategy of health research will be formulated.

4.2.OBJECTIVES:

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4.2.1.General objective:

The main objective of this study is to critically assess the current health research situation and to

develop appropriate mechanism for enhancing and improving health research in the Sudan, to meet the

following specific objectives:

4.2.2. Specific objectives:

1- To document the history of health research in Sudan. 2- To evaluate the health research management system, including mechanisms of collaboration between

different research partners.

3- To identify and evaluate the charges and functions of institutions involved in the planning and implementation of health research.

4- To assess the documentation, publication, utilization and dissemination of the result of health research.

5- To find out the presence or absence of priority setting in health research at the institutional and national levels and how t

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