Journal of Public Health VoI. 27, No. 2, pp.

215–221
doi:10.1093/pubmed/fdi024 Advance Access Publication 8 April 2005

Evidence-based public health: what does it

offer developing countries?
Celia McMichael, Elizabeth Waters and Jimmy Volmink

Abstract health emergencies, implement effective and appropriate inter-

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ventions, evaluate the effect of interventions, and allocate human
The global burden of disease and illness is primarily situated
in developing countries. As developing countries have and financial resources.2 As developing countries have limited
limited resources, it is particularly important to invest in resources, it is particularly important to invest in public health
public health and health promotion strategies that are effect- and health promotion strategies that are effective.
ive. Systematic reviews are central to evidence-based public Evidence-based public health refers to public health efforts
health and health promotion practice and policy. This paper
in which there is an informed and explicit use of evidence.3 In
discusses issues surrounding the relevance of evidence-based
public health and systematic reviews to the health of devel- particular, through the systematic appraisal of available
oping countries. It argues that there is a lack of systematic research, public health practice draws directly on evidence that
reviews relevant to the health priorities of developing coun- demonstrates the effectiveness of interventions.4 Systematic
tries; many interventions reviewed can not be implemented reviews are recognised as an important method for facilitating
in resource-poor situations; and, a limited amount of prim-
evidence-informed policy and practice because of their capacity
ary research is conducted in developing countries.
to synthesise the results from multiple studies. They aim to
The paper further argues that improvements in public health
minimize the likelihood of drawing incorrect or misleading
are determined not only by effective health services and
interventions, but through an approach that includes other conclusions through exhaustive search strategies for identifying
sectors and influences broader structural and systematic all existing relevant primary studies, rigorous appraisal of these
barriers to health. Given the social complexity of human studies, and synthesis of study findings using quantitative or
development, and the inter-sections amongst different qualitative methods.5
development goals, there is no question that gains in devel-
However, a key concern for those promoting evidence-based
oping country public health are unlikely to emerge from
systematic reviews alone, but will require decisions about public health, and relying on systematic reviews of research to
inter-sectoral collaboration and social policy initiatives. inform decisions about public health interventions, either from
Nonetheless, evidence around intervention effectiveness the Cochrane Library or those published elsewhere, is that often
has an important role to play in addressing health priorities the available reviews are unable to provide guidance on effective
in developing countries and resource-poor areas. The public
interventions,6 particularly in relation to the health of develop-
health evidence base urgently needs strengthening, with
dedicated effort towards increasing the relevance of primary ing countries. Some reasons why systematic reviews have had a
evidence and systematic reviews. limited role in providing evidence relevant to developing coun-
tries are: (1) there is a lack of systematic reviews that are relevant
Keywords: developing countries, evidence-based public
health, international health, systematic review to the health priorities of developing countries; (2) many inter-
ventions that have been reviewed and shown to be effective can

Background
School of Public Health, Faculty of Health Sciences, La Trobe University,
More than 30 000 children die from preventable causes each day; VIC 3086, Australia
every year more than 500 000 women die in pregnancy and Celia McMichael, PhD, Subject Co-ordinator/Lecturer
childbirth; 38 million people are living with HIV/AIDS and School of Health and Social Development, Faculty of Health and Behavioural
20 million have already died from the disease; 8 million people Sciences, Melbourne Campus at Burwood, Melbourne, Australia
develop active tuberculosis each year of which 2 million die; Professor Elizabeth Waters, MPH, DPhil (Oxon), Chair in Public Health
malaria kills more than 1 million people a year, most of these University of Cape Town, Primary Health Care Directorate, UCT Faculty of
Health Sciences, E47 Old Main Building, Groote Schuur Hospital,
children under 5 years old. This burden of disease and illness is
Observatory, 7925 Cape Town, South Africa
primarily situated in developing countries,1 and offers a stark
Jimmy Volmink BSc, MBChB, DCH, MPH, DPhil, Professor and Chair of
indication of the impact of global inequalities. The primary goals Primary Health Care
of public health are to identify priority health issues, develop fea- Address correspondence to Celia McMichael or Professor Elizabeth Waters.
sible, acceptable and effective health policies, respond to public E-mail: [email protected] or [email protected]

© The Author 2005, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved.
216 JOURNAL OF PUBLIC HEALTH

not be implemented in resource–poor situations; (3) there is a While there are an increasing number of systematic reviews
limited amount of primary research conducted in developing relevant to health care in developing countries,11 Cochrane
countries as compared to high–income countries. These issues reviews of treatment effectiveness have not yet addressed many
limit the usefulness of currently available systematic reviews common medical conditions in developing countries, such as
(and primary research) for decision-makers in developing count- umbilical hernia, gunshot wounds and the commonly used
ries. This paper discusses the above challenges, critically consid- anaesthetic ketamine.12 It would also be extremely valuable for
ering the role of evidence–based public health and the relevance systematic reviews to address intervention costs so as to allow
of systematic reviews within the context of international health, informed decision-making within the constraints of limited
and makes some suggestions as to how these challenges could budgets in resource-poor settings, but cost-effectiveness is yet to
be overcome. be considered widely. For example, while there are number of
Cochrane reviews and meta-analyses of the effectiveness of strep-
tokinase in acute myocardial infarction, at a cost of approximately
Systematic reviews and international health 250 USD per dose, aspirin, a less costly but potentially equally

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effective treatment, is yet to be reviewed.13
Currently available systematic reviews do not reflect A possible reason for the lack of review questions addressing
developing world priorities priority issues for developing areas is that there is a discernible
Systematic reviews have tended to reflect the priorities of difference in output between reviewers from developing coun-
developed countries rather than the global disease burden.7 tries (or with significant developing world experience) and those
Swingler et al analysed nearly 3000 reviews from the Cochrane from developed countries. A survey of the place of residence of
database of systematic reviews and the Database of Abstracts Cochrane reviewers from 1997 to 2003 suggests that although
of Reviews of Effects (DARE) and assessed the correlation the number of reviewers from developing countries has
between the number of reviews and burden of disease. They increased since the beginning of the period, the relative propor-
found that few systematic reviews focus on diseases and aspects tion of reviewers from developing countries compared to
of health care affecting large numbers of the world’s popula- developed countries has declined from 16 per cent in 1997 to 8
tion.8 per cent in 2003 (Fig. 2). This highlights the need for a pro-
Two-fifths of the world’s population live in high mortality gramme of training and support for reviewers from developing
developing countries, where relatively few risk factors account countries.
for the high rates of disease and injury. The 10 leading factors The Cochrane Collaboration has recently embarked upon a
threatening health globally are underweight, unsafe sex, high ‘Developing Country Initiative’ that seeks to actively encourage
blood pressure, tobacco consumption, alcohol consumption, the participation of reviewers from developing countries. In
unsafe water, sanitation and hygiene, iron deficiency, indoor addition, through entities such as the Effective Practice and
smoke from solid fuels, high cholesterol, and obesity.9 In high Organisation of Care Collaborative Review Group and the
mortality developing regions, underweight, unsafe water, sani- Health Promotion and Public Health Field, the Collaboration
tation and hygiene, and indoor smoke from solid fuels are lead- has begun to prioritize reviews focusing on macro-level deter-
ing risks to health. Approximately one–sixth of the entire minants of health that are particularly pertinent to low- and
disease burden in these regions is attributable to underweight middle-income countries. But these activities will have to be
and micronutrient deficiencies, unsafe sex accounts for around substantially increased in the years ahead to redress the current
one-tenth of all disease burden, and unsafe water for a further imbalances and to ensure that systematic reviews play a more
4–5 per cent of the burden (Fig. 1).9 prominent role in helping to achieve the millennium develop-
For some areas of public health, primary research and ment goals set by the United Nations.
systematic reviews have relevance for both developed and devel-
oping countries. In the case of HIV/AIDS, for example, there Many interventions reviewed cannot be implemented
has been a rapid development and testing of a vaccine to combat in resource-poor situations
specific strains of the AIDS virus.1 Furthermore, while tradi- Even where reviews are nominally relevant, the treatment and
tionally associated with ‘Western’ countries, non-communicable interventions advocated may be unavailable or inappropriate in
diseases – including cardiovascular disease, diabetes, cancers low-income countries.14 For example, anti–retroviral (ARV)
and obesity-related conditions – are contributing to a growing drugs have the potential to dramatically improve the health and
burden of disease in low- and middle-income countries.10 Accord- extend the lives of some people with HIV/AIDS. Brocklehurst
ingly, systematic reviews relating to non-communicable diseases and Volmink’s Cochrane review of anti–retroviral treatment
have increasing relevance to developing countries. However, for reducing the risk of mother-to-child transmission of HIV
there is a relative absence of reviews of many priority health infection concludes that antiretroviral therapy will have an
issues in developing countries, such as child and maternal under- immediate benefit for countries with the resources to adopt
nutrition and environmental risks (sanitation and hygiene) – such treatment.15 In developed countries anti-retroviral therapy
which account for 3 million deaths a year.7 is used frequently to reduce new HIV infections, and to reduce
 EVIDENCE-BASED PUBLIC HEALTH 217

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Figure 1 Amounts and patterns of burden of disease in developing and developed countries. Source: WHO: World Health
Report 2002, p. 81.

occurrence of opportunistic infections and AIDS deaths. How- has highlighted the fact that of the 73 billion USD invested
ever, the high cost and demanding clinical infrastructure neces- annually in global health research, less than 10 per cent is spent
sary to use these drugs put them out of reach of the vast on research into the health problems that account for 90 per cent
majority of people with HIV. This problem is especially acute in of the global disease burden. There is also a systematic bias in
developing countries, where HIV infection levels are high and medical journals against diseases and health needs that dominate
public resources are extremely scarce.16 Brocklehurst and the least–developed regions.17,18 Furthermore, in developing
Volmink state that the search for effective, affordable, safe and countries, much knowledge is unpublished and consequently
acceptable alternatives to anti-retroviral therapy for use in can not be included in systematic reviews. This cultural and
resource-poor countries should remain on the research agenda. geographical bias in the availability and relevance of published
Meanwhile, policymakers in developing countries face mounting public health literature is a significant problem.
public pressure to pay for the expensive drugs that are currently The evidence typically perceived to have the greatest credibility
available (at a cost of 175–993 USD per month). is the randomized controlled trial (RCT).19 Where an evidence-
base exists for the effectiveness of interventions, it might be
Limited amount of primary research is conducted assumed that the challenge is to make the interventions avail-
in developing countries able to poor populations in the developing world.20 However,
The local relevance of health research for developing countries the results of trials conducted in developed countries may not
is limited as most research is generated in developed countries.14 be transferable to different populations. Developing country
Captured in the expression ‘the 10/90 gap’, the Global Forum populations differ from those recruited in typical clinical trials.
218 JOURNAL OF PUBLIC HEALTH

1800

1600

1400

Number of reviews
1200

1000
Developed countries
800 Developing countries

600

400

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200
8% 8%
16% 12% 9% 9% 8%
0

Issue 3/97 Issue 3/98 Issue 3/99 Issue 3/00 Issue 3/01 Issue 3/02 Issue 3/03
Issue of CDSR

Figure 2 Number and proportions (%) of Cochrane reviews by location of contact author in developing/developed countries,
1997–2003.

‘Third-world’ patients may have patho-physiological differ- randomized controlled trials of healthcare interventions; the
ences in response to treatment, often present late, may be self- European Developing Country Partnership (EDCTP) funds
medicating with ‘prescription’ drugs or traditional treatments, trials of pharmaceutical treatments for malaria, tuberculosis
have co-morbidities (i.e. malnourishment, anaemia, malaria), and HIV/AIDS. Initiatives such as these are likely to signifi-
may be unable or unwilling to adhere with treatment, have cul- cantly increase the number of RCTs relevant to decision-
tural, behavioural and attitudinal differences, and poor facilities making about health care in developing countries.
and resources influence treatment effectiveness.13 In contrast, a However, evaluation studies need to explore more than
typical patient in a RCT carried out in a high-income country intervention efficacy under trial conditions. In order for evidence
experiences none of these problems. Further, there are many to inform decision–making, it needs to address the prevailing
contextual factors that have a significant bearing on the effec- problems, the complex pathways to health outcomes, and the
tiveness of an intervention and on which outcomes are most effectiveness of interventions in local contexts.22 There is
important, including social, cultural, infrastructure, health pro- increasing recognition that, in addition to controlled trials that
file and economic characteristics. Accordingly, many interven- identify intervention efficacy, successful evaluation of public
tions that have been shown to be efficacious in industrialized health interventions will necessarily entail the use of a range of
countries have not been similarly effective when delivered to research designs that are better placed to answer questions
people and populations in the developing world.20 about other relevant outcomes, such as appropriateness and
In comparison to developed countries, few RCTs are avail- feasibility, and to provide evidence around implementation
able from developing countries and efforts must be made to issues in particular settings and contexts.23,24 A recent publi-
increase the number of RCTs conducted in developing count- cation by the NHS Centre for Reviews and Dissemination gives
ries and that ask relevant questions about effectiveness. While recognition to the diverse types of evidence that can contribute
RCTs conducted in developing countries are in the main method- to systematic reviews. The recently published GRADE guide-
ologically acceptable, the analysis carried out by Pienaar et al. lines and the draft ‘Guidelines for systematic reviews of health
of RCTs published in the South African Medical Journal promotion and public health interventions’ also provide frame-
between 1948 and 1997 found that there were a number of defi- works for inclusion and analysis of study designs that extend
ciencies in the quality of the trials.21 Initiatives are in place to beyond the RCT.25,26 The growing acknowledgement of the
increase the capacity of researchers in developing countries to role of other study designs, in addition to RCTs, provides scope
carry out rigorous trials evaluating intervention.2,11 For for the inclusion of a greater number and range of studies of
example, PRACTIH (Pragmatic Randomized Controlled Trials relevance to developing countries. This development might also
in Health Care) is a European Union-funded initiative which allow developed countries to benefit from the vast experience
provides tools and training to researchers in developing coun- developing countries have in implementing low-cost com-
tries who are interested in designing and conducting pragmatic munity-based programs.27
 EVIDENCE-BASED PUBLIC HEALTH 219

Case study: systematic reviews of malaria of health and political systems, cultural and economic
treatment and prevention settings, and the physical environment. Accordingly, there are
different possibilities for increasing the relevance of system-
The challenges of preventing and treating malaria provide an atic reviews and evidence-based public health to developing
example of the disjuncture between evidence-based public countries.
health and its relevance to developed countries. The Roll Back One approach is to address priority topics by carrying out
Malaria campaign, launched in 1998, aims to halve the burden systematic reviews of public health topics of global import-
of disease by the year 2010. The focus is on sub-Saharan Africa, ance. As published previously, the Cochrane Collaboration’s
and it is proposed to implement effective and cost-effective Health Promotion and Public Health Field has recommended
control strategies.28,29 However, the annual number of deaths priority systematic reviews of public health topics of global
worldwide from malaria is higher now than in 1998.30 importance and of particular relevance to developing coun-
A recent analysis of the Cochrane Library identified tries. Criteria for priority selection included burden of disease,
13 systematic reviews that focus on the effectiveness of drugs magnitude of the problem, urgency, importance to developing

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for treating malaria and associated conditions and 1 review countries, and opportunity for action.7,34 Examples of recom-
focusing on insecticide–treated bed nets and curtains for mendations include systematic reviews of: community-building
prevention of malaria. Dans notes that malaria treatment interventions to improve physical, social and mental health;
protocols vary depending on drug resistance patterns which interventions that use a combination of environmental, social
alter response to treatment, and this can limit the applicabil- and educational strategies to prevent infectious diseases such
ity of trial results.13 While effective treatments are a pivotal as malaria; non-testing dependent prevention of mother to
component of malaria control, other public health priorities – child transmission of HIV. Other alternatives include sub-
such as inter-sectoral collaboration, education and social group analysis of primary research and evaluation in every
policy – have not been addressed in systematic reviews. In review to distinguish rich/poor country evidence, involving
order to ‘roll back malaria’, it is necessary to determine not more people from developing countries or with developing
only which drugs and bed-nets effectively prevent and treat country experience in the review process, and explicit acknowl-
malaria, but also how to improve health systems capacity, edgement of contextual heterogeneity in relation to implement-
resources and infrastructure; increase advocacy, inter-sectoral ation of interventions.
collaboration and community partnerships; improve tech- Opportunities exist for improving the evidence-base for
nical capacity and management in relation to surveillance, public health and health promotion in developing countries. As
diagnosis and treatment; respond to and address natural Horton notes, however, health policymaking involves an
disasters, migration, urban growth and poverty.31 Further- uneasy balance of science, economics and politics.35 Many
more, the evidence-base around cost-effectiveness of malaria deaths in developing countries are preventable through treat-
prevention and treatment is limited, and its potential to ments and interventions such as use of bed nets, affordable
inform policy is limited by lack of information on the costs antibiotics, and basic hygiene and health education. But there
and effects of many interventions, and the problems of com- is common agreement that improvements in public health are
paring studies that relate to specific settings and outcome determined not only by effective health services and interven-
measures.32 tions, but through an approach that includes other sectors and
This case example illustrates that there is a need for more influences broader structural and systematic barriers to
systematic reviews of priority global health issues, and which health.1,36,37 The UN ‘Millennium Development Goals’ –
use evidence drawn from local settings. In order to contribute eradication of extreme poverty and hunger, universal primary
to international health efforts, reviews should focus not only on education, promotion of gender equality, reduction of child
primary prevention and treatment, but also on macro-level mortality, improvements to maternal health, combating HIV/
determinants of health, such as increasing the capacity of health AIDS, malaria and other disease, ensuring environmental
services. sustainability, and developing a global partnership for
development – complement each other, with gains in one
area contributing to better outcomes in the others.38 For
Increasing the potential for systematic example, gender equality will increase girls’ access to education
reviews to contribute to the health of which allows them to engage in economic activity outside the
people in developing countries home, facilitates use of medical services for themselves and
The Cochrane Handbook states that ‘while [reviewers] cannot their children, and promotes better family planning. This
be expected to be aware of the myriad differences in circum- improves livelihoods and health outcomes, and decreases child
stances around the world, they can address differences of mortality.1 While an evidence-base for effective public interven-
known importance to many people’.33 Differences of known tions is critical, gains in health may best be achieved through
importance to public health interventions include the burden frameworks that focus on the links between health, education,
of disease and illness, availability of resources, characteristics gender equality and poverty reduction.
220 JOURNAL OF PUBLIC HEALTH

Conclusion funded by the Australian Commonwealth Government, Depart-

ment of Health and Ageing.
Evidence-based public health promotes use of the best available The Cochrane Health Promotion and Public Health Field,
evidence on the effectiveness and lack of effectiveness of inter- based in Victoria, Australia, acknowledges the generous sup-
ventions. Significant efforts are required, however, to increase port of the Victorian Health Promotion Foundation
the relevance of systematic reviews to public health priorities in (VicHealth), and the Australian Commonwealth Government,
developing countries and resource–poor areas: the questions Department of Health and Ageing.
and scope need to consider heterogeneous contexts to ensure Thanks to Lucie Rychetnik, from the School of Public
relevance, and difficult decisions need to be made about the Health, University of Sydney, for her comments on an earlier
availability and adequacy of the primary research to address draft of this paper.
the question. Given the social complexity of human develop-
ment, and the inter-sections amongst different development
goals, there is no question that gains in developing country References

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