Searching for Science Evidence Use and Knowledge Production in Global Health

Abstract

Evidence-based medicine (EBM) emerged in the early 1990s, unifying attempts to apply scientific methodologies to clinical care. EBM contains three central components: (1) evidence hierarchies to rank research findings, (2) systematic reviews to synthesize randomized control trials (RCTs), and (3) guidelines for cost-effective health interventions. EBM has since migrated into global health policy and become the default metric for designing programs, prioritizing treatments, and measuring outcomes. The promise of EBM has been to produce health policies based on ‘scientific knowledge’ – objective, value free, and independent of socio-political influences. The reality of the application, however, has not been neutral. Within EBM, evidence acquires the meaning of ‘what works’ and policy decisions are transformed into technical questions of best practice or cost-effectiveness. Global health realities are often at odds with the prevailing paradigm of EBM. Evidence-based approaches privilege questions that can be answered by randomized control trials (RCTs). Other health issues, of equal or even higher importance, can become neglected if they are easily amenable to RCT evaluations. EBM’s emphasize on the observable and measurable has promoted a trend towards techno-centric interventions that targeted specific diseases at the expense of broader health determinants. This thesis presents a critical analysis of EBM. I evaluate the EBM movement along three dimensions: historical, methodological, and political. In the historical analysis, I explore how and why the EBM movement took place and the global health environment in which EBM later evolved. In the methodological analysis, I assess the components of EBM directly and, in particular, the ‘gold status’ of RCTs in evidence-based policy. Finally, I assess the extent to which EBM has influenced global health policy-making, for better and for worse. By examining these three dimensions, I address the larger issue of how knowledge is integrated into global health policies. In evaluating EBM’s broader and systematic influence on global heath policy, three findings emerge: 1) RCTs do not necessarily produce objective policy recommendations for global health programs. In fact, RCTs can be misused as a ‘tool’ for policy-makers, yielding results that distort the development of more meaningful heath policy priorities. 2) EBM takes on different forms across health settings. In contrast to the transformation EBM caused in clinical care, it has been selectively applied in policy development. 3) EBM can mislead policy development by providing the illusion of a simplified system for determining the “cost-effectiveness” of treatment programs. Rather than turning to evidence-evaluation frameworks to determine priorities or initiatives, the relative merits of evidence are used only when policies are in dispute. EBM has become a tool for globalization and neoliberal transitions, rather than a objective method for the overall improvement of human health.