About STP
Scenarios
Background
Local evidence can be used to: | |
---|---|
• Estimate the magnitude of the problem or issue that the policy aims to address | |
• Diagnose the likely causes of the problem [34] | |
• Contextualise, and make relevant, evidence from global reviews of the effects of interventions (e.g. by providing comparative information on the range and outcomes of interventions implemented locally) | |
• Help select priorities for the development of evidence-informed policies and programmes | |
• Describe local delivery, financial, or governance arrangements for healthcare | |
• Inform assessments of the likely impacts of policy options (i.e. due to the existence of modifying factors) | |
• Inform judgements about values and preferences regarding policy options (i.e. the relative importance that those affected attach to possible impacts of policy options) and views regarding these options | |
• Estimate the costs (and savings) of policy options | |
• Assess the availability of resources (including human resources, technical capacity, infrastructure, equipment) needed to implement an intervention | |
• Identify barriers to implementing policy options | |
• Monitor the sustainability of programme effects over time | |
• Examine the effects of a policy option on particular local groups | |
• Examine the equity impacts of a programme following implementation |
A number of countries have amended their malaria policies to replace chloroquine with sulfadoxine-pyrimethamine as the first-line drug for malaria treatment, due to the growing levels of parasite resistance to chloroquine. In Tanzania, the impetus to amend treatment policies was based in part on evidence of a cure rate of approximately 40% for chloroquine, compared to 85-90% for sulfadoxine-pyrimethamine. This local evidence of the magnitude of the problem was drawn from sentinel sites across the country and linked to the growing burden of malaria morbidity and mortality observed in the country [35]. In some Latin American countries, there is concern regarding the extent to which the pneumococcal vaccine includes the serotypes that are common in the region. In order to estimate the size of this potential problem, information from local sentinel sites has been used to evaluate the match between the serotypes included in the vaccine and those prevalent in the region. In Brazil, for example, it was estimated that 67.5% of the cases of invasive disease in children under 5 years of age were produced by serotypes included in the seven valent pneumococcal conjugate vaccine [36]. |
The importance of involving consumers and communities in decisions regarding their healthcare is recognised widely. In Australia, the Consumers' Health Forum undertook consultations with consumers and consumer organisations to explore their needs and expectations regarding general practice. This evidence was gathered to inform policy development for the delivery of general practice services and the improvement of relations between key stakeholders. The evidence was fed into a number of Australian policy processes, including the government's General Practice Reform Strategy, the General Practice Strategy Review, and the development of co-ordinated care as proposed by the Council of Australian Governments [37]. The local acceptability of community-based malaria control interventions provides another example of consumer and community involvement. Indoor residual spraying (IRS) and insecticide-treated nets - the two principal strategies for malaria prevention - are similar in cost and efficacy. The acceptability of these interventions varies across settings. In South Africa, both research and routine programme monitoring have highlighted community dissatisfaction with the IRS insecticide, DDT. This is due to the residue that DDT leaves on house walls and because it stimulates nuisance insects such as bedbugs. In certain areas of Mozambique, there are concerns that specific sleeping habits - for example, people sleeping outside due to the heat - might also negatively influence the uptake of nets [38, 39]. |
WHO policy recommends the use of direct observation of treatment (DOT) for treatment delivery for tuberculosis (TB). DOT can be delivered in a number of ways, including through primary healthcare clinics and in the community. An alternative policy option is for patients with TB to self-supervise their own treatment. A study was done in Cape Town, South Africa to assess the costs associated with each of the clinic, community and self-supervised options for treatment delivery. Local data were used to assess the resource input requirements of these three alternative options over a six month period of treatment. These data were then used to estimate the cost per patient treated for each of the three supervision approaches. The results indicated that the cost (in South African Rands) per patient was R3,600 for clinic supervision, R1,080 for self supervision, and R720 for community supervision. The authors concluded that community-based DOT by a volunteer lay health worker may be less costly to the health services than either clinic-based or self supervision [40]. This cost information influenced the city's decision to expand the delivery of DOT using community-based lay health workers. Policymakers in a Latin American country needed information on the costs of cochlear implants in order to assess the potential costs and savings of interventions to treat hearing loss. A search for local literature using Google identified a report from the Ministry of Health of Chile in which the costs were outlined for the replacement of various components needed for cochlear implants. These data were used to estimate the likely total cost of cochlear implants in the local setting. (The report can be found at: http://www.minsal.cl/ici/rehabilitacion/consentimiento_informado.pdf) |
An increasing number of countries are adding the new human papillomavirus (HPV) vaccine to routine immunisation schedules or are considering doing so. The vaccine is highly effective against the strains of the virus responsible for approximately 70% of cervical cancers and has been recommended for routine immunisation in adolescent girls in the United States. However implementation across the country is thought to be uneven. A study was undertaken in an area of North Carolina which had high rates of cervical cancer. The study explored barriers to vaccine delivery and uptake as perceived by healthcare providers. Medical practices noted a number of key concerns including: inadequate reimbursement by insurance companies of the vaccination costs, the high cost of the vaccine (given that many consumers who needed it did not have adequate health insurance), the burden on practices in ascertaining the availability of insurance cover for each patient (given the varying policies of different insurers), and the high up-front cost to practices of purchasing and storing the vaccine. The study authors note that these resource concerns may act as barriers to the implementation of the national vaccination policy [41]. |
A national programme for the rollout of comprehensive HIV and AIDS care, including antiretroviral treatment (ART), has been implemented in South Africa. The Joint Civil Society Monitoring Forum - a local forum including a number of NGOs research institutes and other stakeholders - was established to assist government with the effective and efficient implementation of the programme. A briefing document outlining the lessons from this process notes that: "Democracy may be portrayed by the public's ability to contribute to and influence the state's decisions and programmes. With regard to [ART] rollout, it has been reported that access to information has been a major challenge. Reportedly not all provinces have been willing to provide information in this regard. This has made monitoring and development of appropriate resolutions difficult" ([42] p3-4). The report also highlights difficulties with obtaining disaggregated data on HIV and AIDS expenditure. It notes how these difficulties, in turn, create problems with monitoring how global HIV/AIDS budgets are being spent, particularly with regard to relative spending on treatment versus prevention, care and support [42]. This example highlights the need for local evidence to effectively monitor the implementation of a key health programme. |
Questions to consider
1. What local evidence is needed to inform a decision about options?
An Australian study of the factors affecting recreational physical activity found that while people living in disadvantaged areas had similar levels of access to public open space as those in wealthier locations, the equipment and space available in the disadvantaged areas were of lower quality. The study suggested that this may explain lower levels of use of these spaces in disadvantaged areas [43]. A province in Argentina detected an increase in maternal mortality. When looking for explanatory reasons, a recent local study was identified in which the causes of maternal mortality were assessed. The report also evaluated those aspects of healthcare that needed to be modified in order to decrease mortality. This local study suggested that abortion was the most common cause of maternal death. (The report is available at: http://www.aagop.com.ar/articulos/CEDES.pdf) |
In Argentina, an evaluation was conducted of a regulation related to payments for obesity treatments, such as bariatric surgery. A national survey of cardiovascular risk factors was used to assess the extent to which obesity was a national problem. This survey provided data on the proportion of people who were overweight or obese and could therefore be used to assess the likely impacts of making different forms of obesity treatment available. (This survey is available at: http://www.msal.gov.ar/htm/Site/enfr/resultados_completos.asp) Canadian stakeholders participating in a deliberative dialogue about how to improve access to primary healthcare in Canada considered a variety of options. All of these included some form of transition from care which was physician-led to care which was team-led. An evidence brief, drawing on local evidence, was prepared to inform the dialogue. This identified four potential barriers to the implementation of the options: |
1. Initial wariness among some patients of potential disruptions to their relationship with their primary healthcare physician |
2. Wariness on the part of physicians of potential infringements on their professional and commercial autonomy, in the light of the private delivery component of the 'private delivery/public payment' arrangement with physicians |
3. A potential lack of viability in terms of organisational scale in many rural and remote communities, and |
4. Government willingness to extend public payment to other healthcare providers and teams while at the same time maintaining the existing public payment to physicians, as part of the 'private delivery/public payment' arrangement with physicians. This was considered to be a particular concern during a recession [44] |
2. How can the necessary local evidence be found?
Local collected data obtained from the routine health information system
-
Risk factors: Such as nutrition and blood pressure
-
Mortality and burden of disease: This includes health outcomes such as child mortality, TB treatment outcomes, peri-operative deaths, infectious disease and cancer notifications
-
Health service coverage:
-
∘ Coverage for clinical interventions or services such as childhood vaccinations or cervical screening rates
-
∘ Health service utilisation information such as length of hospital stay, number of outpatient visits for specific health conditions, and prescription drugs dispensed
-
∘ Routine surveys of patient satisfaction with care
-
-
Health systems resources:
-
∘ Healthcare expenditures according to various cost centres and programmes
-
∘ Human resource data such as numbers and grades of staff in different facilities and programmes, staff development programmes delivered, and staff absenteeism
-
∘ Clinical performance data such as post-surgical infection rates, time to treatment for people with myocardial infarctions
-
∘ Guidelines used for care delivery
-
∘ Adherence to guidelines for care delivery
-
-
Inequities in healthcare and health outcomes
Data from larger surveys or studies that can be disaggregated to local level
Specific studies that have collected and analysed data on a local area
-
By searching (ideally with the help of an information specialist) global databases of published research papers, such as PubMed, the Cochrane Library or the WHO regional databases (e.g. the Latin American and Caribbean Health Sciences Database [LILACS]), using geographic terms such as 'Caracas' or 'Buenos Aires'. PubMed includes a hedge, or validated search strategy, that allows users to search for administrative databases studies, community surveys and qualitative studies (these may be helpful in providing information on utilisation patterns and on views and experiences, for example). This is available at: http://www.nlm.nih.gov/nichsr/hedges/search.html
-
By searching (ideally with the help of an information specialist) sources of 'grey' or unpublished literature, such as Google Scholar, the WHO Library Information System http://dosei.who.int/uhtbin/cgisirsi/Mon+May++4+21:00:46+MEST+2009/0/49, and OpenSIGLE (System for information on grey literature in Europe: http://opensigle.inist.fr). Many local studies, such as operational research on health services, are published as reports on the web but may not be published in research journals. Grey literature is therefore a good source of such evidence
-
By contacting local researchers in universities, research institutes or health departments or local research networks for relevant information, including unpublished study reports
-
By contacting or searching the resources of health observatories such as the European Observatory on Health Care Systems http://www.euro.who.int/observatory, the International Observatory on Mental Health Systems http://www.cimh.unimelb.edu.au/iomhs, or the Africa Health Workforce Observatory http://www.afro.who.int/hrh-observatory
3. How should the quality of the available local evidence be assessed?
Main quality criteria | Sub-questions | Example of the assessment of the quality of local evidence: routinely collected data on TB treatment outcomes from TB Registers |
---|---|---|
Is the evidence representative? | • Is there a clear description of the source of the evidence? • If the evidence is drawn from a sample of the population of interest, is there a clear description of how the sampling was conducted? • Was the sampling approach appropriate (where applicable)? • Is there a description of how any inferences or generalisations were made to the wider population? | TB Registers should routinely record information on each patient diagnosed with TB. The information is not based on a sample of the population of interest. It should therefore be representative of the demographics and treatment outcomes for people with TB in a particular setting, provided that it is completed for each person with TB |
Is the evidence accurate? | • Is there a clear description of who collected the data? • Were the data collectors appropriately trained and supported in this task? • What tools were used for data collection? • Were appropriate tools used? • When were the data collected? • Was the quality of the data collected monitored and was the quality shown to be adequate? • How were the data analysed? • Was the method of analysis reported clearly? • Were any data limitations discussed? | Most health authorities provide a manual, based on WHO guidance, for completion of the TB Register. This generally specifies what information should be collected and by whom. In using these data, policymakers need to check whether there is clear guidance on completion of the Register, whether TB programme staff have been trained in its use, whether there are mechanisms in place to check the quality of the data at clinic and district levels, and whether data compilation was done appropriately |
Are appropriate outcomes reported? | • Is there a clear description of the outcome/s measured? • Is the outcome measure reliable? • Were these outcomes measured appropriately? • Do these outcomes provide a reasonable assessment of the health issue? | A standard range of measures is generally included in TB Registers, based on WHO guidance. These are designed to assess the functioning of the TB programme. However, the data do not generally provide direct measures of issues such as patient satisfaction with the care provided by TB programme staff |
-
Is the evidence representative? This question focuses on whether the evidence correctly represents the wider population from which it is drawn or to which the findings are generalised. There are several components to this question: firstly, is there a clear description of the source of the evidence? Secondly, if the evidence is drawn from a sample of the population of interest, is there a clear description of how the sampling was conducted, and was the sampling approach that was used appropriate? Thirdly, is there a description of how any inferences or generalisations were made to the wider population?
-
Is the evidence accurate? This question is concerned with whether the available data match, or are likely to match, the actual value of the outcome measured. When addressing this question, the user may want to consider whether there are clear descriptions of the processes through which the data were collected. Issues that should be addressed include: who collected the data and were they appropriately trained and supported in this task, what tools were used for data collection, when were the data were collected, was the quality of the collected data monitored, how was the analysis done (were the methods of analysis reported clearly), and were any data limitations discussed
-
Are appropriate outcomes reported? This question focuses on whether the measures reported in the data (such as treatment outcomes or health utilisation measures) are suitable for addressing the question for which the data will be used. When addressing this question, the user may want to consider whether there is a clear description of the outcome or outcomes measured, whether they are reliable, and whether these outcomes will provide a reasonable assessment of the health issue. If policymakers are considering, for example, how to improve the quality of care for people with TB, routinely-reported TB treatment outcomes may be a useful measure. This is because the completion of TB treatment is likely to be related to the quality of care received by patients
4. Are there important variations in the availability, quality or results of local evidence?
Availability
Quality and results
-
Differences in the way in which the issue was defined and measured across the sources
-
Differences between the individuals, groups or other entities about whom data were collected across the sources
-
Differences in the comparators used
-
Differences (where applicable) in the interventions delivered
-
Differences in the ways in which data were collected and analysed across the sources
-
Is the variation potentially important from a clinical or policy perspective?
-
If the variation is important, is a reasonable explanation clear from the data sources, or can a reasonable explanation be hypothesised (e.g. differences in recruitment, measurement, analysis etc.)?
-
Are there other sources of information against which the local evidence can be compared?
5. How should local evidence be incorporated with other information?
-
Describe the approach used to identify the local evidence. Ideally a systematic approach to accessing this evidence should be used
-
Describe the approach used to assess the local evidence. As noted earlier, a systematic approach to assessing evidence is recommended. When shortcuts are necessary, or it is necessary to make assumptions or use informal observations, these should be made transparent
-
Describe clearly what local evidence is used and from where the evidence is obtained. This should include detail related to the specific groups or communities from which the evidence is drawn. As far as possible, documents and other sources should be cited and made available to others involved in the decision making process
-
Describe any important gaps or uncertainties in the evidence due to the lack of local information or its poor quality. A study of the use of data available from the national Australian Childhood Immunization Register, for example, found that there were challenges in using the Register to adequately measure immunisation rates and outcomes in specific populations, such as remote indigenous groups [13]. Similar uncertainties have been reported from LMICs [23, 24]. There may also be uncertainties in evidence due to conflicting findings between different sets of local evidence. For example, hospital mortality rates, complication rates, or duration of stay in intensive care may all be used to assess the quality of surgical care. Studies have found a poor correlation between these different indicators [18, 25, 26]. Consequently, it may be difficult to decide which set of data best reflects the 'real' quality of surgical services in a hospital or region and therefore which dataset should be used to inform policymaking. The applicability of local evidence to particular population subgroups may also be uncertain. For example, local evidence on teenage pregnancy rates may be available for the general population but not available by population subgroups (e.g. by ethnicity or language)
-
Finally, it is important to identify and discuss any differences between the findings obtained from global evidence and those obtained from local evidence. For example, global evidence suggests that lay health workers can be effective in improving the uptake of immunisation in children [27]. However, local evidence might suggest otherwise if there are strong local views that lay people are inadequately qualified to provide health advice. In this instance, the promotion of this cadre would be less effective locally. Such local evidence might lead to less confidence (i.e. greater uncertainty) about the applicability of global evidence on lay health workers for immunisation uptake, even though the global review would still be seen as providing the best available estimate of effectiveness. Caution also needs to be used in applying economic evidence from other settings to a particular jurisdiction as the relative costs of some inputs may vary greatly across settings. For example, human resource costs generally vary locally while pharmaceutical costs may be similar across settings.
Conclusion
Stage of the policy cycle | Use of local evidence | Types of local evidence that might be relevant |
---|---|---|
Diagnosing the problem or goal | To estimate the magnitude of the problem or issue that the policy aims to address and stakeholders' views on it | • Vital statistics data from routine sources, surveys such as the national DHS • Morbidity data from routine sources at national, sub-national or institutional (e.g. hospital) level • Local studies of stakeholder views and experiences |
To diagnose the likely causes of the problem | • Local studies of stakeholder views and experiences • Data on risk factors from surveys | |
To describe local delivery, financial or governance arrangements for healthcare | • Ministry of Health and Ministry of Finance policies, guidelines and records • Regulations of professional organisations | |
Assessing policy options | To contextualise evidence from global reviews of the effects of interventions and to make this evidence relevant | • Data from local health delivery agencies on the range of interventions currently implemented (for a particular health problem) and their outcomes, which can be compared with the programmes evaluated in global reviews • Data from local health delivery agencies on local coverage of these interventions |
To inform assessments of the likely impacts of policy options (e.g. due to the existence of modifying factors) | • Local studies of similar programmes | |
To inform judgements about values and preferences regarding policy options (i.e. the relative importance that those affected attach to possible impacts of policy options) and views regarding these options | • Local studies of stakeholder views • Information from stakeholder organisations, e.g. organisations representing the public and specific consumer groups, such as those living with particular health problems • Information from deliberative dialogues with stakeholders | |
To estimate the costs (and savings) of the policy options | • Local studies of programme costs and savings • Cost data held by health departments or programmes or by non-governmental delivery agencies | |
Examine the effects of a policy option on particular local groups | • Routinely collected programme data • Local studies focusing on the group/s of interest | |
Exploring implementation strategies for a policy option | To assess the availability of resources (including human resources, technical capacity, infrastructure, and equipment) | • Resource data held by health departments or programmes or by non-governmental delivery agencies • Local studies of resource use by similar programmes |
To identify barriers to implementing policy options | • Local studies of stakeholder views • Information from stakeholder organisations, e.g. organisations representing the public and specific consumer groups, such as those living with particular health problems • Information from deliberative dialogues with stakeholders • Local barrier studies | |
Monitoring the effects of a policy option | Monitor the sustainability of programme effects over time | • Routinely collected programme data |
Examine the equity impacts of a programme following implementation | • Data that can be disaggregated by gender, age, area of residence, etc. |
Resources
Useful documents and further reading
-
WHO. World Health Statistics. Indicator compendium (Interim version). Geneva: World Health Organisation. 2009 http://www.who.int/whosis/indicators/en/.
-
The 'Creating Excellence' network in the United Kingdom has produced a short local evidence guide and a toolkit on gathering and analysing local level data. http://www.creatingexcellence.org.uk/regeneration-renewal-news262.html
-
Department for Education and Skills, United Kingdom. Using local evidence. A leaflet for service managers, planners and commissioners. http://www.dcsf.gov.uk/everychildmatters/_download/?id=5728