FORUM Open Access
Global health: the importance of evidence-based
Gretchen L Birbeck1, Charles S Wiysonge2, Edward J Mills3,4, Julio J Frenk5, Xiao-Nong Zhou6and Prabhat Jha7
Global health is a varied field that comprises research, evaluation and policy that, by its definition, also occurs in
disparate locations across the world. This forum article is introduced by our guest editor of the Medicine for Global
Health article collection, Gretchen Birbeck. Here, experts based across different settings describe their personal
experiences of global health, discussing how evidence-based medicine in resource-limited settings can be
translated into improved health outcomes.
Keywords: Global health, Policy, Evidence-based medicine, Research output, Research methodology, Poverty,
Infectious diseases, Health coverage, Resource-limited settings
Introduction: linking more effective research to
better healthcare, policy and health outcomes
Gretchen L. Birbeck
This Medicine for Global Health forum article ad-
dressing the who, what, where, when, and so what of
evidence-based medicine in resource-limited settings
(RLS) includes a collection of commentaries by re-
nowned people from a broad range of geographic set-
tings and a wide array of disciplines. Understanding
the drivers of success (and also failure) of different
aspects of global health can aid the advancement of
better health outcomes.
Charles Shey Wiysonge (Stellenbosch University, South
Africa) calls for increased research and research capacity
from local researchers in RLS. Although the volume of re-
search on health issues in these regions of the globe has
increased exponentially in the last decade, much of the
research agenda is still determined by western funding
agencies and conducted by western researchers. More
leadership by local investigators would better assure that
local health priorities are addressed in research and the
findings of the work are effectively communicated to
policy makers so evidence can be positioned to make
Edward Mills, a Canada Research Chair for Global
Health at the University of Ottawa, points out that
unfortunately, where resources are limited, healthcare
providers tend to be overwhelmed and under-funded. As
a result, one substantial barrier to local research leader-
ship in RLS is the reality that the same overburdened
medical personnel who are trying to provide healthcare
for the masses are needed to lead research endeavors—
usually with inadequate funding, very limited research
training, and insufficient local expertise in biostatistics
and clinical research methodologies (not to mention no
time!). He suggests that the tenuous balance between
service provision and the conduct of research could be
partially addressed by developing a new cadre of re-
searcher and by local research capacity building in bio-
statistics and clinical methods.
What follows are excellent examples of what can
happen when the right questions are addressed and
action taken. Julio Frenk (Dean of the Harvard School
of Public Health and former Minister of Health of
Mexico) explains how epidemiologic evidence from
the Global Burden of Disease work showed Mexico’s
protracted epidemiological transition with an impen-
ding tsunami of non-communicable diseases (NCDs)
in the setting of gross underfunding for healthcare.
Major healthcare reforms followed which included uni-
versal healthcare and a legal mandate that the healthcare
package provided must be reviewed and updated regu-
larly based upon epidemiologic evidence and resource
* Correspondence: firstname.lastname@example.org
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Birbeck et al. BMC Medicine
Mexico is not alone in its progress. Xiao-Nong Zhou,
Director of the National Institute of Parasitic Disorders
at the Chinese Center for Disease Control and Preven-
tion, reviews the substantial advances China has made
toward the Millennium Development Goals. Poverty
levels are down and health status measures are up, but
the news is not all good. Emerging data indicate that the
burden of parasitic diseases may be shifting and ex-
panding as the planet heats up.
Finally, in his inspiring contribution, Prabhat Jha of
the University of Toronto reminds us that modest re-
sources well-directed can have major health effects. His
compelling story of India’s Million Death Study, funded
through a collection of small grants largely targeted at
quantifying tobacco-related health hazards, ultimately
provided evidence that stimulated action and policy
changes related to a diverse range of health-related
issues, including 4 to 12 million ‘missing girls’ from gen-
der selective abortions, a previously unappreciated bur-
den of adult malaria deaths and unrecognized HIV/
AIDS healthcare needs. Professor Jha credits transpa-
rency and open source technology for facilitating data
dissemination and appropriate responses by those direc-
ting policy and legal structures needed to respond to the
Universal healthcare in Mexico, poverty reduction
associated with improvements in population health in
China, modestly funded projects with major public
health findings and subsequent responses from policy-
makers in India—these examples illustrate that what
is happening in RLS today offers lessons for researchers
and policy-makers the world over.
GLB has no competing interests to declare.
Research for health in Africa - time to move on
Charles Shey Wiysonge
Research for health (or health research) denotes the
creation of knowledge that can be used to promote, re-
store, maintain, protect, or monitor the health of human
populations . Health research seeks to answer ques-
tions concerning health, produce evidence required to
guide policy and practice, and identify new healthcare
interventions . Contextualized health research is cri-
tical to ensure healthcare effectiveness, efficiency, and
Gretchen L. Birbeck is a Professor at the University of
Rochester and adjunct faculty at the University of Zambia.
With residences in both Zambia and the US, she conducts research,
provides clinical services and trains the next generation of clinical
researchers on both continents. She has been recognized as a US
Paul Rogers Society Global Health Research Ambassador and a
World Health Organization Ambassador for Epilepsy. She was a
National Finalist for the C. Peter Magrath University/Community
Engagement Award for her two decades of work as the Epilepsy
Care Team Director at Chikankata Hospital in rural Zambia.
Charles Shey Wiysonge is the Deputy Director of the Centre
for Evidence-based Health Care at Stellenbosch University. He is
a specialist in evidence-based medicine and vaccinology. Before
moving into research, Dr. Wiysonge held senior positions in
Cameroon’s Ministry of Public Health. His research is united by a set
of questions regarding strategies for promoting and protecting
health and preventing disease and death in Africa as well as an
engagement with systematic reviews and knowledge translation.
Dr. Wiysonge was decorated by the Presidency of the Republic of
Cameroon in 2011 with the National Order of Valour (the highest
honor in Cameroon), in the category ‘Chevalier.’
Birbeck et al. BMC Medicine
Page 2 of 9
equity in Africa . Research publications have an essen-
tial role in the scientific process, providing a strategic
connection between knowledge generation and its trans-
lation into policy and practice . It is, therefore, of con-
cern that research publication output capacity of African
researchers is disproportionately lower than that of their
western counterparts [4,5].
The relatively low research productivity in Africa is
multifactorial in origin . Important contributors to
this problem include the non-alignment of in-country
research to national research policies and the nonexis-
tence of national research policies with well-defined pri-
orities [7-9]. The health research field in Africa seems to
be characterized by numerous players, varied interests,
scattered efforts, and uncertain outcomes in relation to
impact on the major health challenges of the continent
[4,5]. Organizations based in the North sponsor most of
the research reported from Africa [5,8]. In addition,
many African countries do not have norms and stan-
dards for developing collaborative research agreements
with external institutions [7,8]. Without such norms and
standards, it is likely that research priorities will be
influenced more by the agendas of foreign institutions
than by the health requirements and concerns of host
countries. Thus, although North–South collaboration is
desirable, it is important to question the national owner-
ship of research conducted in African countries under
such circumstances. National ownership is essential, as it
helps to ensure that national assets are used judiciously
and that the host population benefits from research.
We recently conducted a bibliometric analysis of
childhood immunization research from Africa and found
that research productivity on the continent is highly
skewed, and that African researchers make only a min-
imal contribution to global research output. In addition,
we found no significant association between immu-
nization research productivity and immunization cover-
age (incidence rate ratio 0.38, 95% confidence intervals
0.04 to 3.42) . We attributed the lack of association
between increased research productivity and improved
service delivery to the lack of sharing of research evi-
dence between researchers and policymakers for transla-
tion into policy and public health action.
Africa is a large and complex continent and, despite
some countries already having strong research profiles
[4,5], optimal growth and efficiency overall can only be
realized if the way forward is charted in a systematic and
coordinated manner. Increased political commitment to
health research by African governments and their de-
velopment partners would be indispensable for such
growth. Political commitment can best be accomplished
by defining a clear and considered plan for Africa’s fu-
ture research enterprise, incorporating a robust accoun-
tability framework. The research strategic plan should
offer due credit to systematic reviews and knowledge
translation . Systematic reviews are summaries of
existing research in which bias and chance have been
minimized by a systematic identification, critical ap-
praisal, and synthesis of all relevant studies on a specific
topic according to a transparent and predetermined
process . Without systematic reviews, limited re-
search resources on the African continent will continue
to be wasted on unnecessary research and needless con-
fusion will persist from failure to interpret the results of
new research in the context of other relevant research
. Knowledge translation encompasses all mecha-
nisms for facilitating the uptake of research evidence
into policy and practice [13,14]. The research strategic
plan and ensuing accountability framework should be
used both politically and technically at continental and
national levels to bring greater policy consistency and
advocate for better action from governments and devel-
opment partners, in order to increase research output in
Africa and spread the full benefit of research to all sec-
tors of the African society by 2015 and beyond.
CSW is grateful to Prof Jimmy Volmink for critical rea-
ding and discussion.
CSW has no competing interests to declare.
Balancing research with healthcare in resource-
Edward J. Mills
RLS are also the environments in which undertreated
diseases thrive and guidance on how to treat those con-
ditions effectively is limited . For these reasons, there
is both an enthusiasm for conducting locally relevant
randomized clinical trials (RCTs) and a need to find out
what works in a simple and cost-effective way. Despite
this enthusiasm, there are several important impedi-
ments that make the widespread conduct of RCTs in
most resource-limited settings challenging. These can be
impediments conferred on poor settings by outside orga-
nizations as well as internal domestic challenges. Herein,
I outline what I believe are the three most important
First, as with almost all poor settings, human resources
for health are consistently inadequate for delivering
healthcare. There is a constant push-pull influence of re-
search on healthcare as most organizations want to be
seen to do research but do not have the requisite staff to
conduct quality research. In many circumstances, physi-
cians and clinical officers are prioritized for research
training that inevitably takes them away from seeing pa-
tients. However, unless the research is paid for by an
Birbeck et al. BMC Medicine
Page 3 of 9
international organization, physicians and health staff
may lose income by conducting research rather than car-
ing for patients. There is a clear need to prioritize indi-
viduals for research methods training and a specific
cadre of health researchers may be a strategy to increase
specialty skills while minimizing the negative effects on
the health system. In the absence of paid and allotted
time for an individual to conduct research, it is not real-
istic for an effective clinical research environment to
Second, there is a specific need for training in biosta-
tistics and clinical research methodology. In my experi-
ence, there are many excellent health workers, typically
physicians, involved in clinical research projects. How-
ever, almost consistently absent are biostatisticians and
methodologists. This is important for two reasons: one
is to provide input to the design and interpretation of
externally funded and designed research; and two is to
be able to conduct the analysis at a local level regardless
of external collaboration. Some international organi-
zations, such as the International Clinical Epidemio-
logy Network (INCLEN), have recognized this  and
made important efforts to build capacity by partnering
organizations and mentors. However, this needs to occur
with every country that has an active research agenda
and prioritizing high-level biostatistics will require an in-
vestment by domestic ministries of health. This is a par-
ticular challenge in most settings as the highest qualified
biostatisticians and methodologists are frequently recrui-
ted by international organizations that can pay much
better salaries than domestic ministries.
Third, there is the need for freedom of decision-
making for researchers. This is a particularly nuanced
topic as every culture is different. Because health typic-
ally has a hierarchy of decision-making power, often led
by the most senior physicians and then subsequent
cadres of workers, the freedom for a junior researcher to
critique common practice is limited. In many cultures,
questioning authority is considered rude. Similarly, the
research agenda may already be set by an external funder.
For example, U.S. Agency for International Development
(USAID) supported organizations may be mandated to
meet USAID needs. Innovative strategies to provide small
research grants may be one method to identify new and
innovative locally-relevant research topics. Organizations
such as Grand Challenges Canada and the Micro-research
grants project recognize this .
Unless these challenges can be directly addressed by
both domestic and international agencies and funders,
then conducting RCTs will remain the domain of well-
funded external collaborators. In the new era of global
health education, it will be a shame if we do not build
and support the infrastructure for long-term, locally-
relevant clinical research.
EJM has no competing interests to declare.
Knowledge to transform global health and policy:
the success of universal health coverage in
Julio J. Frenk
Knowledge is the most powerful force for enlightened
social transformation. When it is translated into evi-
dence, it provides a solid foundation for policy design
and program implementation.
Before becoming dean of the Harvard School of Public
Health, I lived through the fascinating experience of
conducting a large-scale reform of a health system. This
process reached a major milestone in 2012, when Mexico
announced to the world the achievement of universal
health coverage (UHC). With more than 50 million previ-
ously uninsured persons now covered through a new pub-
lic insurance scheme, this developing country has reached
a globally cherished goal that has nonetheless eluded most
poor nations and a notorious rich one.
Edward Mills is Canada Research Chair in Global Health at
the University of Ottawa. He is adjunct faculty at the National
University of Rwanda and Stanford University. He is trained in both
Clinical Epidemiology and International Law. He works predominantly
on issues of HIV/AIDS in Africa. In addition, he runs a statistical
methods group that conducts clinical trials and meta-analysis.
Birbeck et al. BMC Medicine
Page 4 of 9
UHC was reached through a reform that was designed
and implemented making use of evidence derived from
the local adaptation of knowledge-related global public
goods, such as the measurement of global burden of
disease, the framework for health system performance
assessment and the methods for calculating national
health accounts, among others.
Thus, the analysis of the burden of disease showed
that Mexico was undergoing a protracted and polarized
epidemiological transition characterized by the complex
coexistence of an unfinished agenda (common infec-
tions, maternal mortality, under-nutrition) with emer-
ging challenges (NCDs, injuries, mental health problems,
obesity). The Mexican health system, however, had not
kept up with the pressures derived from this transition.
At the turn of the century, Mexico was spending only
5.6% of its gross domestic product (GDP) on health, far
below the average figure for the Latin American region
(6.7%). Even worse, more than half of the total health ex-
penditure was out-of-pocket, which exposed households
to major financial shocks. This was a direct result of the
fact that approximately half of the population lacked
Such evidence generated the advocacy tools to pro-
mote a legal reform establishing in 2003 a system of so-
cial protection in health which has reorganized and
increased public funding by a full percentage of GDP
over eight years in order to provide universal health in-
surance through a new public scheme called Seguro
Popular (SP). This insurance scheme guarantees access
to a comprehensive package of cost-effective services
covering the prevention, early detection, diagnosis, treat-
ment, and palliation of the major causes of ill health, in-
cluding NCDs. The law stipulates that the package must
be progressively expanded and updated annually on the
basis of changes in the epidemiologic profile, techno-
logical developments and resource availability. The grad-
ual expansion of population and intervention coverage,
coupled with demand-side subsidies and supply-side in-
centives for efficiency, made this a fiscally responsible
and sustainable reform—and garnered the crucial sup-
port required from the Ministry of Finance.
The reform was also subject to a rigorous external
evaluation which showed major impacts. A community
trial developed in 2005/2006 demonstrated that SP is
expanding access to health services, reducing out-of
-pocket expenditures and providing protection against
poorest households .
The Mexican experience shows the importance of mo-
bilizing knowledge in pursuit of socially valued policy
objectives. Now the evidence produced by this national
reform feeds back into the global pool of experience,
thus generating a process of shared learning.
JJF has no competing interests to declare.
Reducing the burden of infectious diseases
associated with poverty in China
In order to meet the eight Millennium Development
Goals (MDGs) by 2015, more international communities
and countries are taking further actions on human de-
velopment issues. At the same time, they are also seek-
ing the solutions to the post-2015 agenda for sustainable
development, since many counties or regions will have
difficulty in achieving these goals by the 2015 deadline.
China is one of few developing countries that has
made enormous progress towards the achievement of its
MDGs. Since 1990, poverty, especially absolute poverty
in rural areas, has been greatly reduced, life expectancy
has increased to 74.8 years, the maternal mortality ratio
has dropped to 26/100,000, and the infant mortality rate
is currently 12/1,000 [19,20]. Due to the efforts to
Julio Frenk is the Dean of the Faculty at Harvard School of
Public Health and T & G Angelopoulos Professor of Public
Health and International Development, a joint appointment
with the Harvard Kennedy School of Government. Dr. Frenk
served as the Minister of Health of Mexico from 2000 to 2006, where
he introduced universal health coverage. He was the founding
director of the National Institute of Public Health of Mexico and has
also held leadership positions at the Mexican Health Foundation, the
World Health Organization, and the Bill and Melinda Gates Foundation.
Birbeck et al. BMC Medicine
Page 5 of 9
control infectious diseases, there has been a significant
decline in both the prevalence and disease burden of in-
fectious diseases in China compared to 60 years ago
Similar to other developing countries, China is facing
challenges in its sustainable human and economic de-
velopment. First, there is a need to balance regional
economic growth with equitable and sustainable devel-
opment. Second, China’s already stressed environment is
experiencing additional stress caused by rapid industria-
lization, urbanization and the significant increase in in-
dividual consumption. These challenges have a negative
impact on the quality of public health. For example, cer-
tain neglected tropical diseases, such as soil-transmitted
helminthiasis and schistosomiasis, affect more than 465
million people in P.R. China [23,24]. These diseases tend
to disproportionately affect those living in the remote
rural areas who are relatively resource-poor . There-
fore, greater efforts are required for China to take fur-
ther actions on combating these infectious diseases of
One of the ways to tackle infectious diseases of pov-
erty better is to identify research gaps and set priorities
towards eliminating these diseases. I was involved in a
World Health Organization (WHO) think tank compris-
ing more than 100 experts that aimed to address these
issues through various seminars and workshops. In par-
ticular, as the co-chair of the WHO Thematic Reference
Group on Environment, Agriculture and Infectious Dis-
eases, we made important recommendations with regard
to trans-disciplinary research priorities using the one-
health approach . These aim to break the cycle of
the infectious diseases and poverty, and focus on issues
such as environmental changes, innovative technology,
social determinants and health systems .
In particular, the impact of climate change on the
transmission of infectious diseases of poverty within low
and middle income countries was recommended as one
of the high priorities . A specific example, and one
on which my research efforts are focused, is the in-
creased potential transmission of schistosomiasis due to
global warming . Based on our biology-driven model,
our group found that global warming would result in an
increase of transmission of schistosomiasis japonica, due
to disease epidemic areas extending northwards into
currently non-endemic areas, and transmission intensity
increasing during transmission season . Employing
time-series modelling and geostatistical analysis of tem-
perature records supported by geographic information
system (GIS) and remote sensing (RS) technology, we es-
timated that a surface area of 41,335 km2could become
potential schistosome-transmission areas, putting an
additional 21 million people at risk for an infection with
Schistosoma japonicum . No doubt such a result has
a profound public health impact and is of considerable
economic significance. Our field studies also illustrated
that climate change contributes to an increased fre-
quency of extreme climate events, resulting in increased
rainfall and widespread flooding which caused the resur-
gence of schistosomiasis along the Yangtze River after
the big flood of 1998 . Therefore, it is worthwhile to
apply an integrated tool employing a GIS/RS approach
and modeling methods in the prediction of the potential
distribution areas of schistosomiasis under global war-
ming scenarios .
XNZ has no competing interests to declare.
Xiao-Nong Zhou is Director of the National Institute of Parasitic
Diseases at the Chinese Center for Disease Control and
Prevention, based in Shanghai, P.R. China. Currently, Professor
Zhou is serving as Chair of the National Expert Advisory Committee
on schistosomiasis and other parasitic diseases for China’s National
Health and Family Planning Commission (formal Ministry of Health).
He has collaborated with WHO/TDR and WHO, for instance he is
member of WHO/TDR STAC, member of WHO STAC on NTDs,
member of WHO Foodborne Burden Epidemiology Reference
Group. He had contributed to the Regional Network on Asian
Schistosomiasis and Other Helminth Zoonoses during 2007 to 2012
as former President and to the WHO Thematic Reference Group on
Environment, Agriculture and Infectious Diseases during 2009 to
2011 as co-chair.
Birbeck et al. BMC Medicine
Page 6 of 9
Transparency in counting the dead and
Prior to 2004, it had been difficult to assess accurately
what killed Indians since India is a country similar to
most other low and middle-income countries where death
registration by cause remains uncommon and most deaths
occur at home without medical attention. To address the
fundamental gap, the Million Death Study (MDS) was
launched in 2004. Led by the Registrar General of India
(RGI), the MDS has employed a simple, practical and
action-oriented approach to survey the causes of death
from an enhanced verbal autopsy [35,36]. Among the
findings thus far:
? HIV/AIDS resulted in 0.1 million deaths (UNAIDS
estimated 0.4 million ) in 2004; this result led to
adjustments in AIDS funding to align better with
actual demand for life-prolonging therapies.
? Smoking caused approximately one million deaths
 in 2010; this finding led India’s government to
introduce warning labels on cigarette packages and
raise tobacco taxes to help reduce consumption .
? Malaria caused 0.2 million deaths (13 times the
WHO estimate ) in 2005 primarily among
adults; within one week, this finding led to
public demand for greater control of malaria in
the state of Orissa (and spurred other, currently
inconclusive, research on adult malaria deaths
? Selective abortion of females accounts for about 4 to
12 million ‘missing girls’, with about half of these just
in the last decade ; within 10 days of
publication, this finding prompted stricter rules on
? Two million child deaths occurred in 2005
(down to 1.5 million in 2012) from five avoidable
causes ; this finding spurred the expansion of
neonatal/intra-partum care and is presently
enabling district-based monitoring of child deaths
and up-to-date estimates of child mortality by
gender. Only about 80 districts comprise nearly
one third of India’s child deaths , while
gender disparities are far more widespread. This
has enabled the ‘district report cards’ to try to
accelerate child mortality declines, focused on
specific introduction of new vaccines, expanded
case management and strategies to reduce
neonatal deaths .
Many of these findings were not predicted in the initial
study design (which was mostly focused on quantifying
tobacco hazards among adults and was funded by three
small National Institutes of Health and Gates Founda-
tion tobacco research grants).
Transparency in these data is important as it helps
build confidence of decision makers and funders in the
results. The field work, training methods and coding
practices in the MDS are all open source (and freely
available at www.cghr.org). This has spurred replication,
which is welcome. We are in active discussion with the
RGI to make the primary data openly available to all re-
searchers to use imaginatively and without restriction.
Unfortunately, too many datasets, including the Global
Burden of Disease remain closed, and hence the basic
scientific standard of reproducibility limits their scien-
tific and public credibility. It takes time to change
government policies based on scientific findings, but I
am confident that India’s tradition of open debate and
democratic institutions will lead to data improving
India gave the world the zero, and now it is showing
the world how reliable, low-cost cause of death data can
transform health strategies.
PJ has no competing interests to declare.
Prabhat Jha is the University of Toronto Endowed Professor in
Disease Control at the Dalla Lana School of Public Health, and
the founding Executive Director of the Centre for Global Health
Research at St. Michael’s Hospital. He is the lead investigator of
the Million Death Study in India, which quantifies the causes of
premature mortality and the contribution of key risk factors, such as
tobacco and alcohol.
Birbeck et al. BMC Medicine
Page 7 of 9
1University of Rochester Medical Center, School of Medicine and Dentistry,
601 Elmwood Ave, Box CU420694, Rochester, NY 14642, USA.2Centre for
Evidence-based Health Care, Faculty of Medicine and Health Sciences,
Stellenbosch University, Tygerberg Campus, Cape Town 7505, South Africa.
3Faculty of Health Sciences, University of Ottawa, 25 University Private,
Ottawa ON K1N 6N5, Canada.4Stanford Prevention Research Center, Stanford
University, 291 Campus Drive, Stanford, CA 94305510, USA.5Harvard School
of Public Health, Kresge Building, Room 1005, 677 Huntington Avenue,
Boston, MA 02115, USA.6Chinese Center for Disease Control and Prevention,
National Institute of Parasitic Diseases, 207 Rui Jin Er Road, Shanghai 200025,
PR China.7Centre for Global Health Research, St. Michael’s Hospital, Dalla
Lana School of Public Health, 30 Bond Street, Toronto M5B 1W8, Canada.
Received: 30 September 2013 Accepted: 30 September 2013
16 Oct 2013
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