Overcoming roadblocks in translating evidence-based healthcare into public health gains

Shobha Shukla and Bobby Ramakant, CNS
Dr Prathap Tharyan,  Director, SACNC
Photo credit: SACNC
Commendable progress has been made in the South Asian region to advance evidence-based healthcare and let evidence inform policy and programmes at different levels. But there have been roadblocks too that are slowing down the progress. Citizen News Service (CNS) spoke with Dr Prathap Tharyan, Director, South Asian Cochrane Network and Centre, who has led from the front on the cause of evidence-based healthcare in this region, and globally. Dr Tharyan is also the co-chair of the 22nd Cochrane Colloquium, which is taking place for the first-time ever in the South Asian region in Hyderabad, India.

When we read about the research study outcomes, it is important to know reliably how strong (or weak) the evidence is. Dr Tharyan said: "Cochrane has developed the ability over the years to help people unwrap a body of research, and not just one study on a topic. It looks at all the studies on a particular topic to cull out all the important outcomes that are really going to make a difference to people. Because by the time a research is done and outcomes are obtained by researchers or by people with vested interests, and while they may show statistical significance (X is better than Y and this difference is not by chance) it may not prove to be a very important study for the people. Cochrane is trying to look at what are the important outcomes and differences regarding a particular topic clinically."
Dr Tharyan's experience shows that people from diverse range of sectors do want evidence to help them take right decisions. "People actually want to know how to use evidence; they just need to be facilitated in this process. It is not that they are not inherently interested, it is just that they may not know how to interpret it, and so they tend to depend on some people's opinions. So given a sustained collaborative approach things will change."

Money crunch: Despite having evidence, governments often struggle to act because of lack of financial resources. "Countries like India where resources are constrained and the government is not able to put the entire money in health alone, we are able to meet only a fraction of the healthcare needs of the population" said Dr Tharyan.

Profit before people: Dr Tharyan added: "We know that a majority of the healthcare needs are met through private sources with people spending money out of their own pocket. Unfortunately the private healthcare services in India are of variable quality—some are very good while others are not. This unregulated private health sector flourishes because it believes in profit. So we are fighting the big challenge of a difference in ideology, whereas ideology should be that healthcare is governed by reasonably good evidence that something works or does not work. For most people in the healthcare industry the bottom line is their bank balance. So very often patients are subjected to unnecessary investigations costing a lot of money and those who want to practice evidence based medicines are considered to be old fashioned. So what the majority believes has become the norm, even though it is based on false premises. Standards of healthcare in the country are now corporate hospitals prescribing unnecessary diagnostic tests that are not required. Medical profession is not providing leadership and there are not many people in it who are trying to change the system for better. It is not taking responsibility for its acts. Majority of young doctors follow their own models who unfortunately are doing the wrong things. This Colloquium is about giving at least some young people a vision of what is possible if we all work together. This is a rare opportunity to interact with people who are fighting for evidence based treatment and diagnostics."

Dr Tharyan has hit the nail right on its head, again. After a strong and clear negative advisory from the World Health Organization (WHO) on use of blood serological tests for diagnosis of active TB disease, and the Indian government's potentially game-changing decision to ban serology tests for TB diagnosis in June 2012 'with immediate effect', its use is still prevalent in the private sector despite mounting evidence against it. This is just one example which underlines how malpractices in private sector continue to negatively impact public health, despite overwhelming strong evidence and policy frameworks.

According to the Medical Council of India (MCI), the number of private medical colleges (215 private medical colleges with 25070 MBBS seats) is more than the government public medical colleges (183 government medical colleges with 24860 MBBS seats) in today's context. It is common knowledge that the medical education costs an astronomical amount of money in private medical colleges compared to heavily subsidized medical schooling in public government medical colleges. Dr Tharyan said: "These days doctors have to spend a lot of money on their education (in private medical colleges). There is subsidised healthcare and subsidised medical education in government setup but not so in private setup."

Despite criticism of pharmaceutical companies funding medical conferences, the trend is not declining. But all is not that dark and we do see light: 22nd Cochrane Colloquium has deliberately not received even a single penny from any pharmaceutical company or manufacturer of medical supplies, a golden trend-setting example for medical and broader healthcare community. The conflict of interest has to be recognized and pharmaceutical companies' public relation exercises in the form of gifts, sponsorships or incentives to medical community must not only be de-normalized but also exposed and shamed.

The very fact that the South Asian region is hosting its first-ever Cochrane Colloquium in Hyderabad sends a promising signal to evidence-based healthcare in the region, and globally. "This meet is a small drop in the ocean, but it is large enough to create a ripple. It has been 10 years since we decided to be a network (SACNC) here in India," he said.

'Opening the gates' of Cochrane Library in India
The goal of evidence-based healthcare becomes more achievable when people from a range of sectors can have free access to quality and reliable evidence. Thanks to the Indian Council of Medical Research (ICMR) and persistent advocacy done by the South Asian Cochrane Network and Centre (SACNC) housed in Christian Medical College (CMC) Vellore among others, the Cochrane Library is free and open to all in India.

But did 'opening the gates' to this goldmine repository of evidence (The Cochrane Library) had a positive outcome in terms of increase in use of evidence for decision-making?

Dr Tharyan shared that: "It has made a big difference. Usage of Cochrane library has grown exponentially from something like 9000 reviews being downloaded to more than a 100,000 downloads today. People are reading/ accessing it more and more. Also a lot many Cochrane users are becoming Cochrane authors and the kind of questions they are asking are relevant to our region in terms of public health and management of diseases in our contexts."

Improving science and ethics
Dr Tharyan further shared: "Overseas people are using us as partners as we are able to contextualize the problems. Also it is increasingly being used in teaching medical students. So the way they are thinking about medicine is changing. Apart from reviewing, we at Cochrane are also doing original research in identifying gaps and finding evidence. While doing research we are trying to improve the quality of research—both the science as well as the ethics. As a direct result of my involvement with Cochrane, I was invited to join WHO International Clinical Trial Registry Bank because of which I met the then Director General of ICMR and he asked me to help do the Indian registry. This registry has a vision and a mission. The mission has been complied with. The vision is to use it to improve the quality of our research. This registry has a template that actually facilitates good research. Methods of doing a good trial are clearly disclosed. We have done a study looking at the  protocols registered in our controlled trials registry and the publications. Hopefully we will change the trajectory of primary research."
Despite WHO recommendation to use a specific drug combination (Primaquine plus Chloroquine) for 14 days in cases of malaria vivax, countries such as India, Sri Lanka and Pakistan were then providing the medication for 5 days. Dr Tharyan and the Cochrane team responded to this gap. They did a  Cochrane review which showed that 14 days of therapy (Primaquine and Chloraquine) was "significantly better" than 5 days of therapy with either Chloroquine alone or with the combination of Primaquine and Chloraquine.

Dr Tharyan's team at Cochrane shared this strong evidence with ICMR and are trying to advocate for policy change with the government in the wake of this evidence since last three years. But drug pricing is a barrier perhaps, as 14 days therapy will cost more than 5 days therapy. "The price of drug has to come down too. Countries like India have competing health priorities and have very limited money, so they deserve low priced medicines more than anyone else" argued Dr Tharyan.

Increased recognition to evidence-based healthcare
ICMR is now commissioning systematic reviews. "They pay for it too and I am part of the panel that calls for systematic reviews in child health. We are working with the policy-makers themselves and they understand the importance of Cochrane work," said Dr Tharyan.

Evidence informs healthcare but does not dictate
Framing of policies can be done with help of researchers but implementation is not part of researchers' work and mandate. "Evidence informs healthcare but it does not dictate. Our job as researchers is to summarize evidences in a truthful manner, abstract them in a form that policy makers can understand and then discuss with them if it can or cannot be implemented. They may say it is good but we cannot use it for certain reasons. This is fair enough. But if they do not know that evidence exists and they do something else then that is really serious. Our job is to be knowledge brokers" said Dr Tharyan.

Breaking silos
Different stakeholders for achieving the formidable goal of sustainable development and health justice will perhaps not deny using evidence-based approaches in their own roles and contexts. Researchers who produce good evidence to inform health policy need pragmatic mechanisms to influence health policy and programming at all levels. Researchers, medical and healthcare workers, politicians, relief and aid workers, media and communication workers, philanthropists, development planners, and all other sectors must not close their eyes to good evidence that is relevant to their contexts. As goes the Chinese proverb: "The best time to plant a tree was 20 years ago. The second best time is now."

Shobha Shukla and Bobby Ramakant
Citizen News Service - CNS
23 September 2014