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Education And Debate

Putting evidence into practice: how middle and low income countries “get it together”

BMJ 2004; 329 doi: (Published 28 October 2004) Cite this as: BMJ 2004;329:1036
  1. Paul Garner, professor (,
  2. Martin Meremikwu, senior lecturer2,
  3. Jimmy Volmink, professor3,
  4. Qian Xu, professor4,
  5. Helen Smith, research associate1
  1. 1 International Health Research Group, Liverpool School of Tropical Medicine, Liverpool L3 5QA
  2. 2 Institute of Tropical Diseases Research and Prevention, University of Calabar, Calabar, PMB 1115, Cross River State, Nigeria
  3. 3 Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory 7925 Cape Town, South Africa
  4. 4 Department of Maternal and Child Health, School of Public Health, Medical Center of Fudan University, Shanghai, People's Republic of China
  1. Correspondence to: P Garner

    The scarcity of resources in poorer countries means that ensuring health care is evidence based is particularly important. A group of workers active in the field describe their experiences of trying to do just that


    Imagine a new drug that reduces the absolute risk of treatment failure by three quarters—a rare situation in the West but a reality in countries where malaria is endemic, and where adding artesunate to existing drugs has this effect on cure.1 In middle and low income countries, life threatening infectious diseases are everywhere: new drugs can therefore have large effects on outcomes, and even modest benefits from new interventions can have a dramatic impact on health overall. In addition, wasting resources on ineffective interventions results in technical inefficiencies and substantial opportunity costs in countries least able to afford them; the Global Fund's purchase of ineffective drugs is a recent example.2

    Since 1990 there has been a massive collective effort, largely fuelled by the Cochrane Collaboration, for people from middle and low income countries to “get it together”—to work collectively to bring research evidence into systematic reviews and to consider ways to ensure the findings are used in clinical practice. We all want to put research into practice, but in the past the emphasis was implementing results from single studies. Now it is widely accepted that we need to “globalise the evidence, and localise the decision”—that is, set the results from a single study in the context of other relevant research.3 4 However, these syntheses of the evidence must then be actively managed to ensure change: they require dissemination, policies and systems that enable change, and influential people motivated to stimulate change. This article highlights some of our experiences and personal observations of preparing reviews and implementing change.

    Shifting global bench marks

    The World Health Organization has …

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