Chapter 2: Principles

There are a number of principles that are not explicitly included in the framework but that are implicit to the work of WHO in this field. As a UN organization, WHO is committed to promote health as a human right and to uphold internationally agreed ethical norms and standards as part of its core function [132]^,[133]. Two other principles have already been presented in other sections of this guide: (i) use of systematic and transparent processes (mentioned in Chapter 1), and (ii) continuous improvement processes (covered as part of the sustain and system change stage of the policy/action cycle in this chapter). Other principles that are important to this framework are presented here, including needs-based approaches, inclusiveness, integration and equity.

Needs-based approaches

Every stage of the framework (both in evidence creation and application) should consider the needs of the target audience at the national or local level. The policy and political context, the resources and other on-the-ground realities of the countries where evidence will be used should be considered when developing specific evidence products or when designing a solution and measuring its impact across the policy/action cycle. This need-based approach will allow the use of evidence by target audiences for improving their health system and the health of their populations.

Inclusive approaches

The perspectives of diverse stakeholders – both in the health sector and in other sectors such as social policy and education – should be incorporated when using the framework to develop evidence products and strategies. This diversity is not only related to the type of evidence used to address diverse types of questions [134] but also to the views of different professions regarding the use of evidence [135] and to the contribution of evidence from other fields to the understanding of problems and the design and implementation of solutions [136]. This multisector/disciplinary collaboration not only has an instrumental value but also contributes to the empowerment of sectors/disciplines often not adequately considered in health policy-making processes.

Integration

The “evidence ecosystem for impact” framework” is conceived as a roadmap for any initiative aimed at promoting the use of evidence in decision-making processes. In that sense, it could be seen as a tool for integrating the work of different departments (workstreams) within WHO (at the three levels of the Organization) and at country level allowing more efficient use of resources and the creation of synergistic effects in institutional capacity for EIDM [69]^,[130]. Likewise, this integration would help to promote exchange of innovations, methods, experiences and resources for the overall advancement of the field. This can include the establishment of partnerships both within WHO and with other organizations (e.g. evidence producers such as Cochrane and Campbell) in order to benefit from their complementary roles to achieve comparative advantages in the production and use of evidence.

The integration principle is also connected to a “system-thinking” approach to the understanding of health systems and how evidence “flows” through the system [137]. This approach places a high value on understanding the contextual elements of any health system and the connections between its components, actors and processes. It also makes deliberate attempts to anticipate the consequences of changes in the system (such as in the policy/action cycle) and to identify opportunities for leveraging such changes, despite the difficulties in predicting and controlling processes in the complex environment in which KT efforts are operating. However, this is the essence of a learning health system that is able to learn through rapid feedback loops integrated in cyclical processes [114].

Collaboration for EIDM in practice

Evidence synthesis, Evidence-to-Decision framework development, and economic evaluation teaming up at the Ministry of Health, Chile

“At the Department of Health Technology Assessment and Evidencebased Healthcare of the Ministry of Health in Chile, our Evidence-Informed Health Policies Unit works side by side with two partner units. While our unit conducts rapid evidence synthesis and deliberative processes for health policies, public health and health system interventions, the Clinical Evidence Unit specializes in clinical evidence syntheses and practice guidelines. Our colleagues in the Economic Evaluation Unit are experts in health economics, cost–effectiveness and budget impact analysis. By joining forces, we can apply our combined expertise to different health issues and cover a wide spectrum of complementary evidence-informed decision-making skills. In 2021, for example, we supported Chile’s national programme on nutritional preventive and recovery support for children, with evidence-informed recommendations for the reformulation of a dairy product. Following our rapid evidence synthesis, we developed a GRADE Evidence-to-Decision process, for which the Clinical Evidence Unit provided methodological support, and the Economic Evaluation Unit contributed a cost–effectiveness analysis. Through our collaboration, we were not only able to deliver a well-reasoned set of recommendations, but additionally strengthened the role and reputation of evidence-informed decision-making in our department and ministry.”

Equity

The framework includes a commitment to improve equity in health as an impact measurement. However, equity should also be considered at each stage of the evidence creation and application domains. In order to have the information needed to make judgements about equity, producers of primary and secondary research should consider reporting their results following guidelines such as CONSORT-Equity and PRISMA-Equity [138]^,[139]. In the same vein, evidence products such as guidelines or EBPs should include equity considerations in their development [140]. Through the policy/action cycle, issues regarding the consequences of different solutions and implementation strategies on disadvantaged populations should be highlighted and the use of specific equity oriented frameworks should be promoted [141].

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