A Flow Diagram to Facilitate Selection of Interventions and Research for Health Care

By Irwig, L.; Zwarenstein, M. et al. | Bulletin of the World Health Organization, January 1998 | Go to article overview

A Flow Diagram to Facilitate Selection of Interventions and Research for Health Care


Irwig, L., Zwarenstein, M., Zwi, A., Chalmers, I., Bulletin of the World Health Organization


Introduction

In poor and rich countries alike, planners and providers of health services and health research face the challenge of deciding how to make effective use of limited or contracting resources. Promoting equitable access to health services is an important health policy objective; however, better access will not improve health unless the care provided does more good than harm. By "good" we mean all positive benefits of health care: an improvement in the quality of life or a prolongation of life. By "harm" we mean the unintended negative consequences to individuals affected by the form of health care in question, whether or not they were the principal focus of the intervention.

This criterion of effectiveness -- doing more good than harm -- can be applied to health care interventions across the board. Examples include the following: curative medical and surgical treatments; the care offered by nursing and other professionals in health facilities or domiciliary settings; preventive immunizations; nutrient supplements; care offered by volunteers in the community; health education in schools; and regulatory or fiscal interventions to encourage health-promoting behaviour.

Policy-making in the health sector is complex and takes place within a given social, economic, and political context. Decision-makers may take different views as to whether a particular service should be provided by the public or private sector and whether it should be financed using public or private resources (1). However, it is becoming increasingly accepted that decisions about health service provision should be informed by valid evidence of the effects of health care interventions, along with an appreciation of the costs of providing such interventions, the competing priorities, and the population's values and preferences. Rationally, this process of decision-making in health care begins with efforts to identify health problems of high priority; i.e. problems that are common, serious, resource-consuming, of community concern, and potentially amenable to interventions (2-4). Decision-makers need reliable evidence to assess the relative merits of alternative strategies for preventing, treating, and researching the priority problems identified.

In recent years, the importance has increasingly been recognized of improving the evidence base for guiding such decision-making by conducting systematic reviews of research evidence (5). This is apparent among those using health care (6) as well as those providing it (7), health research funding bodies (8), those assessing the academic performance of health research institutions (9), government advisory bodies (10), those promoting policy changes (11), and organizations responsible for funding and purchasing health services (12).

The best evidence for the effects of an intervention comes from randomized comparisons of individuals or groups since these avoid the selection biases inherent in observational studies (13). Randomized controlled trials have shown, for example, that aspirin reduces mortality after myocardial infarction by about 23% (14) and that improved treatment of sexually transmitted diseases in rural Africa reduces spread of human immunodeficiency virus (HIV) by up to 40% (15). Analysis of the results of all well-controlled trials in systematic reviews provides powerful evidence for the effects of interventions (16-18). Access to the results of systematic reviews, and to information about reviews being prepared, has now been facilitated through publication of sources such as The Cochrane Database of Systematic Reviews, The York Database of Abstracts of Reviews of Effectiveness and the journal, Evidence-based medicine (19-21).

Against this evolving background, we present in this article a flow diagram as an aid to selecting health care interventions and identifying research needs. The diagram should be helpful as an aid in system-wide planning, in assessing interventions for a single group of health problems, in evaluating a single intervention, and in prioritizing research on health care interventions. …

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