Use of Evidence-Based Medicine in low- and middle- income countries

Evidence-based medicine (EBM) aims to improve health care professionals’ decisions by using scientific evidence available. EBM can be applied to all levels of decision-making in health care; from every-day clinical practice at the physician’s office to purchasing decisions by policy makers. EBM is widely used in high-income countries by individual physicians or large organizations. In these countries, Clinical Practice Guidelines are produced on evidence-based grounds through systematic reviews and/or meta-analyses.

However, the situation is different in low- and middle- income countries as only a small proportion of physicians use EBM in their practice. There is certainly knowledge about the advantages offered by EBM in terms of health care quality. However, there is inadequate and insufficient use of EBM in hospitals and health care centers. Moreover, at a higher decision-making level, selection of essential medicines to be financed by the government is made by committees of experts who base their decisions on experience and personal judgment. Scientific evidence is not frequently used among these committees.

There are several reasons why EBM is not commonly used in low and middle-income countries. Evidence synthesis through systematic reviews or meta-analyses is often produced in high income countries. However, these publications may not always be useful out of these settings. Firstly, access to medicines and interventions in low and middle-income countries is more limited than in high-income countries. There is insufficient public spending and shortages due to problems in supply. Additionally, contextual differences can apply, such as cultural differences. Therefore, the implementation of clinical practice guidelines produced in high-income countries is not always a straight forward process in low and middle-income countries. This type of work should be adapted from a collaborative approach, taking into account structural and organizational differences in specific regions.

Another reason why EBM remains under-used is a lack of knowledge about EBM. It is believed that training of health care professionals in technical aspects of EBM would create better use of scientific evidence and improve quality in clinical practice. Systematic reviewers at a local level would help to search specific evidence and produce reviews where there is no evidence available. Production of systematic reviews has considerably increased in the last decade in low and middle-income countries. However, there is still a gap compared to the production of systematic reviews in developed countries. A recently published study found that more than 20% of developing countries did not produce any systematic reviews in a period of 12 years.

Although EBM may be a desirable practice for health care decision-making, there are still some challenges for implementing this approach in low and middle- income countries. Capacity building initiatives should be promoted to increase knowledge in searching and adapting evidence from different regions and to increase local production of evidence synthesis, according to local needs.

 

References:

Mori AT, Kaale EA, Ngalesoni F, Norheim OF, Robberstad B. The role of evidence in the decision-making process of selecting essential medicines in developing countries: the case of Tanzania. PLoS One. 2014 Jan 8;9(1):e84824.

Mozafarpour S, Sadeghizadeh A, Kabiri P, Taheri H, Attaei M, Khalighinezhad N. Evidence-based medical practice in developing countries: the case study of Iran. J Eval Clin Pract. 2011 Aug;17(4):651-6.

Law T, Lavis J, Hamandi A, Cheung A, El-Jardali F. Climate for evidence-informed health systems: a profile of systematic review production in 41 low- and middle-income countries, 1996-2008. J Health Serv Res Policy. 2012 Jan;17(1):4-10.

Dawson Rose C, Gutin SA, Reyes M. Adapting positive prevention interventions for international settings: applying U.S. evidence to epidemics in developing countries. J Assoc Nurses AIDS Care. 2011 Jan-Feb;22(1):38-52.

Agweyu A, Opiyo N, English M. Experience developing national evidence-based clinical guidelines for childhood pneumonia in a low-income setting–making the GRADE? BMC Pediatr. 2012 Jan 1;12:1.

 

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