Has the NTD community neglected evidence-based policy?

Abstract

Over the past decade, systematic reviews and explicit evidence-based approaches have replaced expert opinion as the basis for health policy [1]. In developing countries, the high disease burden coupled with limited financial resources for health requires governments, donors, and the public to choose between competing public health and clinical care options, and increasingly they turn to ‘‘evidence’’ to inform these decisions. Systematic reviews of the benefits and harms of different policies and treatments are one of the core sources of evidence, providing concise summaries of the available research about effects [2]. Wellconducted systematic reviews aim to minimize bias in presenting and interpreting results. This can arise due to intentional or unintentional selective studies inclusion, selective reporting, uncritical reading of poorly conducted trials, and incorrect inferences from the data across studies [3]. Alongside evidence on effects, decision making requires other information including cost, disease burden, and the acceptability and feasibility of the policy options. Nevertheless, data on effects is fundamental, because if something does not work, it will not impact on health, and it is not cost-effective, irrespective of whether the drug is cheap or expensive. As members of the Cochrane Infectious Diseases Group, we have, over the past twenty years, seen steady growth in the demand for systematic reviews to inform international and national policy decisions in infectious diseases. Our reviews have been used by policy makers as they have made recommendations to scale-up impregnated mosquito nets [4], reintroduce amodiaquine for malaria [5], change the formula of ORS [6], and switch to artesunate for severe malaria [7]. However, not all our systematic reviews support current policies; some identify research gaps, and some cast doubt on the benefits of the interventions. These gaps may indicate further research is required before these interventions can be recommended. The most complicated policy situations are those in which there is limited evidence of public health benefit, yet statements made by experts recommend the policy. If indeed the expert opinion is wrong, then the continued delivery of the intervention may waste public resources, or fail to bring about all of the promised benefits. One such example of a current debate is in routine deworming of all schoolchildren in areas where intestinal helminths occur. The Cochrane review, in light of current guidelines, advocacy, and policies, represents an area where assumed benefit by expert panels is by no means supported by quite a lot of available, reliable research [8]. Whatever the outcome of future recommendations from the World Health Organization and others is, what is important is that independent syntheses by groups external to the advocacy provide reliable summaries that can be considered in decision making. We are concerned that the neglected tropical disease (NTD) academic community has been slow to engage in evidenceinformed policy and debate, and may be falling behind international best practice. This is borne out of a concern that NTDs are important diseases that need treatments, but that international policies need to stay in line with current international expectations of evidence-informed policy to avoid being discredited. To look for evidence to confirm or refute these concerns, we used appropriate systematic methods (Text S1), and present our interpretation of these data as a viewpoint at the request of PLOS NTDs editors. Influential Papers in NTD Policy and the Evidence They Cite